Provider Demographics
NPI:1639284813
Name:KELLER, GREG S (MD)
Entity Type:Individual
Prefix:
First Name:GREG
Middle Name:S
Last Name:KELLER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 10880
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86304-0880
Mailing Address - Country:US
Mailing Address - Phone:928-759-5874
Mailing Address - Fax:928-458-2039
Practice Address - Street 1:3195 STILLWATER DR STE D
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86305-7171
Practice Address - Country:US
Practice Address - Phone:928-708-4545
Practice Address - Fax:928-708-4544
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ31711207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ31711OtherMEDICAL LICENSE
AZ496291Medicaid
AZZ101610Medicare PIN