Provider Demographics
NPI:1922127992
Name:CARY S KELLER MD PC
Entity Type:Organization
Organization Name:CARY S KELLER MD PC
Other - Org Name:SPORTSMEDICINE FAIRBANKS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:S
Authorized Official - Last Name:DEAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-451-6561
Mailing Address - Street 1:1919 LATHROP ST
Mailing Address - Street 2:SUITE 105
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99701-5937
Mailing Address - Country:US
Mailing Address - Phone:907-451-6561
Mailing Address - Fax:907-451-4847
Practice Address - Street 1:1919 LATHROP ST
Practice Address - Street 2:SUITE 105
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-5937
Practice Address - Country:US
Practice Address - Phone:907-451-6561
Practice Address - Fax:907-451-4847
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-28
Last Update Date:2013-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK38793207X00000X, 207XX0005X, 2083S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Single Specialty
No2083S0010XAllopathic & Osteopathic PhysiciansPreventive MedicineSports MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKK150742Medicare ID - Type UnspecifiedGROUP MEDICARE NUMBER