1184770521 NPI number — I. BASIL KELLER, M.D.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184770521 NPI number — I. BASIL KELLER, M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
I. BASIL KELLER, M.D.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1184770521
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/23/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1449
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VERO BEACH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32961-1449
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
772-569-9611
Provider Business Mailing Address Fax Number:
772-569-9615

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3790 7TH TER
Provider Second Line Business Practice Location Address:
STE., 201
Provider Business Practice Location Address City Name:
VERO BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32960-6552
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
772-569-9611
Provider Business Practice Location Address Fax Number:
772-569-9615
Provider Enumeration Date:
01/26/2007

Additional Information

Authorized Official

Authorized Official Last Name:
KELLER
Authorized Official First Name:
IRVIN
Authorized Official Middle Name:
BASIL
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
772-569-6444

Provider Taxonomy Codes

  • Taxonomy code: 207T00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 279265600 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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