Provider Demographics
NPI:1932130838
Name:KELLER, JERI (MD)
Entity Type:Individual
Prefix:
First Name:JERI
Middle Name:
Last Name:KELLER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JERI
Other - Middle Name:
Other - Last Name:HORACEK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 2580
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65801-2580
Mailing Address - Country:US
Mailing Address - Phone:417-829-4620
Mailing Address - Fax:
Practice Address - Street 1:1235 E CHEROKEE ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-2203
Practice Address - Country:US
Practice Address - Phone:417-820-2829
Practice Address - Fax:417-820-8852
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2014-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO116325207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1932130838Medicaid
P00689767OtherRAILROAD MEDICARE
AR175885001Medicaid
MO132680049Medicare PIN
P00689767OtherRAILROAD MEDICARE