Provider Demographics
NPI:1457311722
Name:KELLER, TIM BURKE (MD)
Entity Type:Individual
Prefix:DR
First Name:TIM
Middle Name:BURKE
Last Name:KELLER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 635283
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-5283
Mailing Address - Country:US
Mailing Address - Phone:859-655-4111
Mailing Address - Fax:859-655-4815
Practice Address - Street 1:1500 JAMES SIMPSON JR WAY
Practice Address - Street 2:STE 201
Practice Address - City:COVINGTON
Practice Address - State:KY
Practice Address - Zip Code:41011-0801
Practice Address - Country:US
Practice Address - Phone:859-655-4111
Practice Address - Fax:859-655-4815
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2018-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY33871207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2159159Medicaid
KY64338718Medicaid
KYG86525Medicare UPIN
OH2159159Medicaid
KY080178462Medicare PIN