Provider Demographics
NPI:1083640304
Name:KELLER, GARY A (MD PHD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:A
Last Name:KELLER
Suffix:
Gender:M
Credentials:MD PHD
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Mailing Address - Street 1:43 WHITING HILL RD
Mailing Address - Street 2:STE 300
Mailing Address - City:BREWER
Mailing Address - State:ME
Mailing Address - Zip Code:04412-1005
Mailing Address - Country:US
Mailing Address - Phone:207-973-5035
Mailing Address - Fax:207-973-5042
Practice Address - Street 1:417 STATE ST STE 421
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-6639
Practice Address - Country:US
Practice Address - Phone:207-973-5293
Practice Address - Fax:207-973-5263
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2016-08-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
ME012479208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
D93062Medicare UPIN