Provider Demographics
NPI:1871510784
Name:ROBERT T KELLER MD & ASSCO PA
Entity Type:Organization
Organization Name:ROBERT T KELLER MD & ASSCO PA
Other - Org Name:ROBERT T KELLER MD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:T
Authorized Official - Last Name:KELLER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:817-737-6585
Mailing Address - Street 1:PO BOX 12247
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76110
Mailing Address - Country:US
Mailing Address - Phone:817-737-6552
Mailing Address - Fax:817-732-6597
Practice Address - Street 1:2751 GREENOAKS RD
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76110
Practice Address - Country:US
Practice Address - Phone:817-737-6552
Practice Address - Fax:817-732-6597
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH4975207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0063LZOtherBC
TXDC1238OtherRR MEDICARE
E02240Medicare UPIN
TX0063LZOtherBC