1316933914 NPI number — DR. DAVID JAY KELLER M.D.

Table of content: DR. DAVID JAY KELLER M.D. (NPI 1316933914)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316933914 NPI number — DR. DAVID JAY KELLER M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KELLER
Provider First Name:
DAVID
Provider Middle Name:
JAY
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1316933914
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/19/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3 ALBERT CREE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RUTLAND
Provider Business Mailing Address State Name:
VT
Provider Business Mailing Address Postal Code:
05701-4601
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
802-775-2937
Provider Business Mailing Address Fax Number:
802-773-0934

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
44 BIRCH ST
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
DERRY
Provider Business Practice Location Address State Name:
NH
Provider Business Practice Location Address Postal Code:
03038-2752
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
603-421-9130
Provider Business Practice Location Address Fax Number:
603-421-2451
Provider Enumeration Date:
09/20/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  0420005877 , registered in the state of VT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207X00000X , with the licence number: LT-2804 , registered in the state of NH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 329603 . This is a "CIGNA" identifier , issued by the state of ( VT ) . This identifiers is of the category "OTHER".
  • Identifier: 0004705 , issued by the state of ( VT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00004705 . This is a "BCBS OF VT" identifier , issued by the state of ( VT ) . This identifiers is of the category "OTHER".
  • Identifier: 30208575 , issued by the state of ( NH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4971 . This is a "CAPITAL DIST PHY HEALTH P" identifier , issued by the state of ( VT ) . This identifiers is of the category "OTHER".
  • Identifier: 18145 . This is a "MOHAWK VALLEY PHYSICIAN" identifier , issued by the state of ( VT ) . This identifiers is of the category "OTHER".




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