Provider Demographics
NPI:1083780605
Name:KELLERMAN, ROY A (MD)
Entity Type:Individual
Prefix:DR
First Name:ROY
Middle Name:A
Last Name:KELLERMAN
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 1:35 JOLLEY DR STE 201
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06002-4228
Mailing Address - Country:US
Mailing Address - Phone:860-243-5569
Mailing Address - Fax:860-243-2622
Practice Address - Street 1:35 JOLLEY DR STE 201
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD
Practice Address - State:CT
Practice Address - Zip Code:06002-4228
Practice Address - Country:US
Practice Address - Phone:860-243-5569
Practice Address - Fax:860-243-2622
Is Sole Proprietor?:No
Enumeration Date:2006-11-27
Last Update Date:2021-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT23862207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT73169936OtherCONNECTICARE
CT010023862CT05OtherBLUE CROSS
CT001238625Medicaid
CT010023862CT05OtherBLUE CROSS
CT110008097Medicare ID - Type Unspecified
B84326Medicare UPIN