Provider Demographics
NPI:1497862072
Name:KELLER, PAMELA E (MD)
Entity Type:Individual
Prefix:
First Name:PAMELA
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 1:621 S ILLINOIS AVE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:MASON CITY
Mailing Address - State:IA
Mailing Address - Zip Code:50401-5489
Mailing Address - Country:US
Mailing Address - Phone:641-494-3041
Mailing Address - Fax:641-494-3059
Practice Address - Street 1:635 E US HWY
Practice Address - Street 2:
Practice Address - City:FOREST CITY
Practice Address - State:IA
Practice Address - Zip Code:50436-0000
Practice Address - Country:US
Practice Address - Phone:641-585-2904
Practice Address - Fax:641-585-5417
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA29418207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA19507OtherWELLMARK
IA2099119Medicaid
IAE57095Medicare UPIN
IA2099119Medicaid