Provider Demographics
NPI:1285902106
Name:WARREN KEITH STAFFORD, M.D.
Entity type:Organization
Organization Name:WARREN KEITH STAFFORD, M.D.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:
Authorized Official - Last Name:KLINGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:484-553-3286
Mailing Address - Street 1:8055 WERTMAN RD
Mailing Address - Street 2:
Mailing Address - City:FOGELSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:18051-1820
Mailing Address - Country:US
Mailing Address - Phone:484-553-3286
Mailing Address - Fax:484-214-0347
Practice Address - Street 1:206A S MAIN ST
Practice Address - Street 2:
Practice Address - City:GREER
Practice Address - State:SC
Practice Address - Zip Code:29650-2127
Practice Address - Country:US
Practice Address - Phone:864-989-0230
Practice Address - Fax:864-334-1880
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-06
Last Update Date:2012-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC23690207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC236907Medicaid
E30388Medicare UPIN