1790762110 NPI number — MARK L KELLER M.D.

Table of content: MARK L KELLER M.D. (NPI 1790762110)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790762110 NPI number — MARK L KELLER M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KELLER
Provider First Name:
MARK
Provider Middle Name:
L
Provider Name Prefix Text:
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:
1790762110
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/16/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2115 N KANSAS AVE
Provider Second Line Business Mailing Address:
MIDWEST EAR NOSE & THROAT SPECIALISTS PC
Provider Business Mailing Address City Name:
HASTINGS
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
68901-2644
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
402-463-2431
Provider Business Mailing Address Fax Number:
402-463-2486

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2115 N KANSAS AVE
Provider Second Line Business Practice Location Address:
MIDWEST EAR NOSE & THROAT SPECIALISTS PC
Provider Business Practice Location Address City Name:
HASTINGS
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
68901-2644
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
402-463-2431
Provider Business Practice Location Address Fax Number:
402-463-2486
Provider Enumeration Date:
12/28/2005

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: 207Y00000X , with the licence number:  21286 , 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: 100448410A , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 35441 . This is a "BCBS" identifier , issued by the state of ( NE ) . This identifiers is of the category "OTHER".
  • Identifier: 47053662300 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".