Provider Demographics
NPI:1124039128
Name:KELLER, MARC I (MD,)
Entity Type:Individual
Prefix:
First Name:MARC
Middle Name:I
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 1:206 SUMMIT ST
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05401-3900
Mailing Address - Country:US
Mailing Address - Phone:802-862-3239
Mailing Address - Fax:
Practice Address - Street 1:206 SUMMIT ST
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401
Practice Address - Country:US
Practice Address - Phone:802-862-3239
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2020-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT042.0005602207RA0401X
VT02.0005602207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0004733Medicaid
NH30010121Medicaid
NH30010121Medicaid
VTVT4733Medicare ID - Type Unspecified