Provider Demographics
NPI:1336314475
Name:ROY A. KELLERMAN, MD, LLC
Entity Type:Organization
Organization Name:ROY A. KELLERMAN, MD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ROY
Authorized Official - Middle Name:A
Authorized Official - Last Name:KELLERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:860-243-5569
Mailing Address - Street 1:701 COTTAGE GROVE RD STE A110
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06002-3082
Mailing Address - Country:US
Mailing Address - Phone:860-243-5569
Mailing Address - Fax:860-243-2622
Practice Address - Street 1:701 COTTAGE GROVE RD STE A110
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD
Practice Address - State:CT
Practice Address - Zip Code:06002-3082
Practice Address - Country:US
Practice Address - Phone:860-243-5569
Practice Address - Fax:860-243-2622
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-29
Last Update Date:2010-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT23862207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT010023862CT05OtherBC/BS
CT110008097OtherMEDICARE
CT001238625Medicaid
CTB84326Medicare UPIN
CT001238625Medicaid