Provider Demographics
NPI:1821193178
Name:KELLER, KATHRYN I (MD)
Entity Type:Individual
Prefix:MRS
First Name:KATHRYN
Middle Name:I
Last Name:KELLER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KATHRYN
Other - Middle Name:I
Other - Last Name:KELLER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:5545 E STOP 11 RD
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46237-8616
Mailing Address - Country:US
Mailing Address - Phone:317-497-6800
Mailing Address - Fax:317-497-6801
Practice Address - Street 1:5908 E STOP 11 RD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46237-8683
Practice Address - Country:US
Practice Address - Phone:317-497-6800
Practice Address - Fax:317-497-6801
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01046943A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200163300Medicaid
G58022Medicare UPIN
IN200163300Medicaid