Provider Demographics
NPI:1225168701
Name:KELLER & GOODMAN MD, PA
Entity Type:Organization
Organization Name:KELLER & GOODMAN MD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:GOODMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:352-742-7776
Mailing Address - Street 1:1879 NIGHTINGALE LN
Mailing Address - Street 2:SUITE C-2
Mailing Address - City:TAVARES
Mailing Address - State:FL
Mailing Address - Zip Code:32778-4363
Mailing Address - Country:US
Mailing Address - Phone:352-742-7776
Mailing Address - Fax:352-742-7750
Practice Address - Street 1:1879 NIGHTINGALE LN
Practice Address - Street 2:SUITE C-2
Practice Address - City:TAVARES
Practice Address - State:FL
Practice Address - Zip Code:32778-4363
Practice Address - Country:US
Practice Address - Phone:352-742-7776
Practice Address - Fax:352-742-7750
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-06
Last Update Date:2008-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME66294207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL375405700Medicaid
25425OtherBLUE CROSS
FL33071Medicare PIN