Provider Demographics
NPI:1053417402
Name:KEYSTONE KIDNEY ASSOCIATES, PC
Entity type:Organization
Organization Name:KEYSTONE KIDNEY ASSOCIATES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:SABLESAK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-544-5880
Mailing Address - Street 1:1990 STEAM WAY STE A102
Mailing Address - Street 2:
Mailing Address - City:ROUND ROCK
Mailing Address - State:TX
Mailing Address - Zip Code:78665-2233
Mailing Address - Country:US
Mailing Address - Phone:847-544-5880
Mailing Address - Fax:512-872-5105
Practice Address - Street 1:359 NINA WAY
Practice Address - Street 2:
Practice Address - City:WARMINSTER
Practice Address - State:PA
Practice Address - Zip Code:18974-2826
Practice Address - Country:US
Practice Address - Phone:847-544-5880
Practice Address - Fax:512-872-5105
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-15
Last Update Date:2025-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QL0400XAmbulatory Health Care FacilitiesClinic/CenterLithotripsy
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001121181003Medicaid