Provider Demographics
NPI:1114061728
Name:KELLER, MICHAEL B (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:B
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 1:1700 MARION STREET
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80218-1121
Mailing Address - Country:US
Mailing Address - Phone:303-830-6666
Mailing Address - Fax:303-830-7099
Practice Address - Street 1:1700 MARION STREET
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80218-1121
Practice Address - Country:US
Practice Address - Phone:303-830-6666
Practice Address - Fax:303-830-7099
Is Sole Proprietor?:No
Enumeration Date:2007-02-16
Last Update Date:2013-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO38238207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
COP00087185OtherMEDICARE ID TYPE UNS
CO62233327Medicaid
CO62233327Medicaid
CO505388Medicare PIN