Provider Demographics
NPI:1275567703
Name:KELLER, MARY E (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:E
Last Name:KELLER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5668 E STATE ST
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61108-2464
Mailing Address - Country:US
Mailing Address - Phone:815-229-7580
Mailing Address - Fax:815-229-7585
Practice Address - Street 1:5668 E STATE ST
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108-2464
Practice Address - Country:US
Practice Address - Phone:815-229-7580
Practice Address - Fax:815-229-7585
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2015-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036107717208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036107717Medicaid
020053661OtherRAILROAD MEDICARE
020053661OtherRAILROAD MEDICARE
H45391Medicare UPIN