Provider Demographics
NPI:1679864599
Name:KELLER, STEPHEN (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:
Last Name:KELLER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:330 N WABASH
Mailing Address - Street 2:STE G20
Mailing Address - City:MARION
Mailing Address - State:IN
Mailing Address - Zip Code:46952-2600
Mailing Address - Country:US
Mailing Address - Phone:765-660-7600
Mailing Address - Fax:765-651-7313
Practice Address - Street 1:1130 N BALDWIN AVE
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IN
Practice Address - Zip Code:46952-2536
Practice Address - Country:US
Practice Address - Phone:765-660-7480
Practice Address - Fax:765-382-4495
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-26
Last Update Date:2018-09-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC173346207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201290930Medicaid