Provider Demographics
NPI:1902834443
Name:KELLER, JEFFERY W (MD)
Entity Type:Individual
Prefix:
First Name:JEFFERY
Middle Name:W
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 1:2845 GREENBRIER RD STE 230
Mailing Address - Street 2:PO BOX 8900
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54308-8900
Mailing Address - Country:US
Mailing Address - Phone:920-288-8250
Mailing Address - Fax:920-288-8255
Practice Address - Street 1:2845 GREENBRIER RD STE 230
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54311-6519
Practice Address - Country:US
Practice Address - Phone:920-288-8250
Practice Address - Fax:920-288-8255
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2008-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI37375208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI104365046Medicaid
WI010061732OtherRAILROAD
WI32004300Medicaid
MI104289839Medicaid
MI104365046Medicaid
WI32004300Medicaid