Provider Demographics
NPI:1871151118
Name:KEYSTONE INTERNAL MEDICINE AND WEIGHT LOSS CENTER LLC
Entity type:Organization
Organization Name:KEYSTONE INTERNAL MEDICINE AND WEIGHT LOSS CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:POLLYTIA
Authorized Official - Middle Name:IRENE
Authorized Official - Last Name:PANAGIOTOU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:201-447-3690
Mailing Address - Street 1:PO BOX 1461
Mailing Address - Street 2:
Mailing Address - City:RIDGEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07451-1461
Mailing Address - Country:US
Mailing Address - Phone:201-450-6044
Mailing Address - Fax:
Practice Address - Street 1:255 WEST SPRING VALLEY AVE
Practice Address - Street 2:SECOND FLOOR, SUITE 200
Practice Address - City:MAYWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07607
Practice Address - Country:US
Practice Address - Phone:201-447-3690
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-02
Last Update Date:2019-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty