Provider Demographics
NPI:1639176472
Name:KELLER, VERN ANTOINE (MD)
Entity Type:Individual
Prefix:
First Name:VERN
Middle Name:ANTOINE
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:PO BOX 23666
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39225-3666
Mailing Address - Country:US
Mailing Address - Phone:601-200-4749
Mailing Address - Fax:601-200-5929
Practice Address - Street 1:155 HOSPITAL DR STE 201
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70503-2852
Practice Address - Country:US
Practice Address - Phone:337-289-7999
Practice Address - Fax:337-289-7998
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2021-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME114423208G00000X
MS22054208G00000X
LA021788208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00084714Medicaid
LA1977292Medicaid
MSP01303537OtherRAILROAD MEDICARE
LA330005703OtherRR MEDICARE
LA1977292Medicaid
LAG39712Medicare UPIN
MS337706YJ9XMedicare PIN