Provider Demographics
NPI:1790760544
Name:KELLER, JAY S (MD)
Entity Type:Individual
Prefix:
First Name:JAY
Middle Name:S
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 1:611 W PARK ST
Mailing Address - Street 2:FAPC
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61801
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:611 W PARK ST
Practice Address - Street 2:
Practice Address - City:URBANA
Practice Address - State:IL
Practice Address - Zip Code:61801-2529
Practice Address - Country:US
Practice Address - Phone:217-383-3140
Practice Address - Fax:217-383-4966
Is Sole Proprietor?:No
Enumeration Date:2005-12-14
Last Update Date:2020-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL16383207V00000X
IL036130109207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036130109Medicaid
AL510I160042OtherMEDICARE PTAN
ALD835OtherMEDICARE GROUP PIN
AL1912966847OtherMEDICAID BILLING
AL101902Medicaid
AL51548375OtherBCBS
ALD835OtherMEDICARE GROUP PIN
E68758Medicare UPIN