Provider Demographics
NPI:1821481912
Name:I. BASIL KELLER, M.D.
Entity Type:Organization
Organization Name:I. BASIL KELLER, M.D.
Other - Org Name:I. BASIL KELLER,M.D. NEUROLOGICAL SURGEON, CLINICAL NEUROSCIENCE
Other - Org Type:Other Name
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:DR
Authorized Official - First Name:IRVIN
Authorized Official - Middle Name:BASIL
Authorized Official - Last Name:KELLER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:772-569-9611
Mailing Address - Street 1:PO BOX 1449
Mailing Address - Street 2:
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32961-1449
Mailing Address - Country:US
Mailing Address - Phone:772-569-9611
Mailing Address - Fax:772-569-9615
Practice Address - Street 1:1850 37TH ST
Practice Address - Street 2:SUITE C
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32960-4856
Practice Address - Country:US
Practice Address - Phone:772-569-9611
Practice Address - Fax:772-569-9615
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:I. BASIL KELLER,M.D.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-03-12
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME19360207T00000X, 2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Multi-Specialty
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL051314800Medicaid
FL1821036492OtherUNPI
FL1821036492OtherUNPI
FL051314800Medicaid
FLD84856Medicare UPIN