Provider Demographics
NPI:1790762110
Name:KELLER, MARK L (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:L
Last Name:KELLER
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:2115 N KANSAS AVE
Mailing Address - Street 2:MIDWEST EAR NOSE & THROAT SPECIALISTS PC
Mailing Address - City:HASTINGS
Mailing Address - State:NE
Mailing Address - Zip Code:68901-2644
Mailing Address - Country:US
Mailing Address - Phone:402-463-2431
Mailing Address - Fax:402-463-2486
Practice Address - Street 1:2115 N KANSAS AVE
Practice Address - Street 2:MIDWEST EAR NOSE & THROAT SPECIALISTS PC
Practice Address - City:HASTINGS
Practice Address - State:NE
Practice Address - Zip Code:68901-2644
Practice Address - Country:US
Practice Address - Phone:402-463-2431
Practice Address - Fax:402-463-2486
Is Sole Proprietor?:No
Enumeration Date:2005-12-28
Last Update Date:2012-07-16
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Provider Licenses
StateLicense IDTaxonomies
NE21286207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100448410AMedicaid
NE35441OtherBCBS
NE47053662300Medicaid
NE47053662300Medicaid