Provider Demographics
NPI:1336604024
Name:KEITA, MOHAMED
Entity type:Individual
Prefix:MR
First Name:MOHAMED
Middle Name:
Last Name:KEITA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5030 WARRINGTON AVENUE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19143
Mailing Address - Country:US
Mailing Address - Phone:215-939-1448
Mailing Address - Fax:215-921-8530
Practice Address - Street 1:5030 WARRINGTON AVENUE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19143
Practice Address - Country:US
Practice Address - Phone:215-939-1448
Practice Address - Fax:215-921-8530
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-06
Last Update Date:2019-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPA-PUC-A6414780343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102800991Medicaid