Provider Demographics
NPI:1346207362
Name:KELLER, CANDACE (MD)
Entity Type:Individual
Prefix:DR
First Name:CANDACE
Middle Name:
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 1:2500 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4500
Mailing Address - Country:US
Mailing Address - Phone:601-984-5900
Mailing Address - Fax:601-984-5939
Practice Address - Street 1:2500 N STATE ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4500
Practice Address - Country:US
Practice Address - Phone:601-984-5900
Practice Address - Fax:601-984-5939
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2014-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS08368207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS050000792Medicaid
MSP00462245OtherRAILROAD MEDICARE
MS201397813AOtherBCBS
MSP01236761OtherRAILROAD MEDICARE PTAN
MS00124276Medicare ID - Type Unspecified
MS302I057705Medicare PIN
MSP01236761OtherRAILROAD MEDICARE PTAN
MSD00981Medicare UPIN
MS512I050027 GRPC00697Medicare PIN