Provider Demographics
NPI:1790715282
Name:KELLERT, ARTHUR B (DPM)
Entity Type:Individual
Prefix:
First Name:ARTHUR
Middle Name:B
Last Name:KELLERT
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35519 E MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:MI
Mailing Address - Zip Code:48184-1682
Mailing Address - Country:US
Mailing Address - Phone:734-721-0561
Mailing Address - Fax:734-721-7583
Practice Address - Street 1:35519 MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:MI
Practice Address - Zip Code:48184
Practice Address - Country:US
Practice Address - Phone:734-721-0561
Practice Address - Fax:734-721-7583
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2008-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAK000685213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1074377Medicaid
T97251Medicare UPIN
MI1074377Medicaid