Provider Demographics
NPI:1629158837
Name:KELLER, MICHELE JANINE (DO)
Entity Type:Individual
Prefix:DR
First Name:MICHELE
Middle Name:JANINE
Last Name:KELLER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1040 SIERRA DR
Mailing Address - Street 2:SUITE 400
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46143-7240
Mailing Address - Country:US
Mailing Address - Phone:317-528-4284
Mailing Address - Fax:317-865-8355
Practice Address - Street 1:8135 CALUMET AVE
Practice Address - Street 2:
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321-1701
Practice Address - Country:US
Practice Address - Phone:219-513-2000
Practice Address - Fax:219-513-2001
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2020-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34006200207Q00000X
IN02004192A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHKE-0807822OtherPIN #
OH2005645Medicaid
G34802Medicare UPIN