Provider Demographics
NPI:1003942145
Name:KELLER, SCOTT ROBERT (MD)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:ROBERT
Last Name:KELLER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 PARK PL
Mailing Address - Street 2:
Mailing Address - City:SWANSEA
Mailing Address - State:IL
Mailing Address - Zip Code:62226-2965
Mailing Address - Country:US
Mailing Address - Phone:618-222-9244
Mailing Address - Fax:618-222-9248
Practice Address - Street 1:3 PARK PL
Practice Address - Street 2:
Practice Address - City:SWANSEA
Practice Address - State:IL
Practice Address - Zip Code:62226-2965
Practice Address - Country:US
Practice Address - Phone:618-222-9244
Practice Address - Fax:618-222-9248
Is Sole Proprietor?:No
Enumeration Date:2007-02-25
Last Update Date:2013-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2007011139208000000X
MO2004014306208000000X
IL036.132786208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO209903004Medicaid
MOI72589Medicare UPIN
MO209903004Medicaid