Provider Demographics
NPI:1609861830
Name:KELLER, SCOTT T (DO)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:T
Last Name:KELLER
Suffix:
Gender:M
Credentials:DO
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Mailing Address - Street 1:4120 FIVE FORKS TRICKUM RD SW
Mailing Address - Street 2:SUITE 105
Mailing Address - City:LILBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30047-3130
Mailing Address - Country:US
Mailing Address - Phone:770-921-6900
Mailing Address - Fax:770-921-6313
Practice Address - Street 1:4120 FIVE FORKS TRICKUM RD SW
Practice Address - Street 2:SUITE 105
Practice Address - City:LILBURN
Practice Address - State:GA
Practice Address - Zip Code:30047-3130
Practice Address - Country:US
Practice Address - Phone:770-921-6900
Practice Address - Fax:770-921-6313
Is Sole Proprietor?:No
Enumeration Date:2005-09-14
Last Update Date:2007-10-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA024445207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00275272DMedicaid
GA00275272DMedicaid
GAE89431Medicare UPIN