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

Table of content: (NPI 1184770521)

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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