Provider Demographics
NPI:1174615686
Name:KEYSTONE RURAL HEALTH CONSORTIA INC
Entity type:Organization
Organization Name:KEYSTONE RURAL HEALTH CONSORTIA INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO/ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:G
Authorized Official - Last Name:HAMMERSLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:814-486-1115
Mailing Address - Street 1:90 EAST SECOND STREET
Mailing Address - Street 2:
Mailing Address - City:EMPORIUM
Mailing Address - State:PA
Mailing Address - Zip Code:15834-1302
Mailing Address - Country:US
Mailing Address - Phone:814-486-1115
Mailing Address - Fax:814-486-0404
Practice Address - Street 1:402 EAST SYCAMORE STREET
Practice Address - Street 2:
Practice Address - City:SNOW SHOE
Practice Address - State:PA
Practice Address - Zip Code:16874-0402
Practice Address - Country:US
Practice Address - Phone:814-387-6857
Practice Address - Fax:814-387-6870
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-29
Last Update Date:2011-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007763960018Medicaid
391013Medicare Oscar/Certification