Provider Demographics
NPI:1356314421
Name:KELLER, RICHARD RALPH (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:RALPH
Last Name:KELLER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3103 CAMPBELL ST
Mailing Address - Street 2:
Mailing Address - City:SANDUSKY
Mailing Address - State:OH
Mailing Address - Zip Code:44870
Mailing Address - Country:US
Mailing Address - Phone:419-625-4461
Mailing Address - Fax:419-625-5199
Practice Address - Street 1:3103 CAMPBELL ST
Practice Address - Street 2:
Practice Address - City:SANDUSKY
Practice Address - State:OH
Practice Address - Zip Code:44870
Practice Address - Country:US
Practice Address - Phone:419-625-4461
Practice Address - Fax:419-625-5199
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35049138K207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0528923Medicaid
OH000000131844OtherANTHEM ID #
OH04376OtherPARAMOUNT ID #
OHKEO570802Medicare ID - Type Unspecified
OH04376OtherPARAMOUNT ID #