1962451260 NPI number — BRENDA K KELLER MD

Table of content: BRENDA K KELLER MD (NPI 1962451260)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962451260 NPI number — BRENDA K KELLER MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KELLER
Provider First Name:
BRENDA
Provider Middle Name:
K
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

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:
1962451260
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/28/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 31266
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OMAHA
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
68131-0266
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
402-249-6136
Provider Business Mailing Address Fax Number:
402-502-6823

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4908 CASS ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OMAHA
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
68132-2913
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
402-249-6136
Provider Business Practice Location Address Fax Number:
402-502-6823
Provider Enumeration Date:
05/06/2006

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: 207RG0300X , with the licence number:  18749 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: 18749 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1962451260 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 10026724400 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1962451260 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".




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