Provider Demographics
NPI:1669006433
Name:KELLER, MICHAEL HOWARD
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:HOWARD
Last Name:KELLER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:414 CHAPEL ST
Mailing Address - Street 2:
Mailing Address - City:MARENGO
Mailing Address - State:IL
Mailing Address - Zip Code:60152-3016
Mailing Address - Country:US
Mailing Address - Phone:815-572-1709
Mailing Address - Fax:
Practice Address - Street 1:414 CHAPEL ST
Practice Address - Street 2:
Practice Address - City:MARENGO
Practice Address - State:IL
Practice Address - Zip Code:60152-3016
Practice Address - Country:US
Practice Address - Phone:815-572-1709
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-02
Last Update Date:2020-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant