Provider Demographics
NPI:1134286917
Name:MICHAEL G KELLER DO PA
Entity Type:Organization
Organization Name:MICHAEL G KELLER DO PA
Other - Org Name:INTERNAL MEDICINE ASSOC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:G
Authorized Official - Last Name:KELLER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:409-962-7606
Mailing Address - Street 1:5502 39TH ST
Mailing Address - Street 2:STE 105
Mailing Address - City:GROVES
Mailing Address - State:TX
Mailing Address - Zip Code:77619
Mailing Address - Country:US
Mailing Address - Phone:409-962-7606
Mailing Address - Fax:409-962-6027
Practice Address - Street 1:3133 SABA LN
Practice Address - Street 2:
Practice Address - City:PORT NECHES
Practice Address - State:TX
Practice Address - Zip Code:77651
Practice Address - Country:US
Practice Address - Phone:409-962-7606
Practice Address - Fax:409-962-6027
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-02
Last Update Date:2018-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF1700207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX093658503Medicaid
A67243Medicare UPIN
TX093658503Medicaid