Provider Demographics
NPI:1164466421
Name:KELLER, SEAN C
Entity Type:Individual
Prefix:DR
First Name:SEAN
Middle Name:C
Last Name:KELLER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13100 E 136TH ST
Practice Address - Street 2:STE 1200
Practice Address - City:FISHERS
Practice Address - State:IN
Practice Address - Zip Code:46037-9417
Practice Address - Country:US
Practice Address - Phone:317-678-3100
Practice Address - Fax:317-678-3108
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2020-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01053956208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200449180Medicaid
INM400021039Medicare PIN
INH84691Medicare UPIN
IN147070HMedicare PIN
INP00859160Medicare PIN