Provider Demographics
NPI:1962451260
Name:KELLER, BRENDA K (MD)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:K
Last Name:KELLER
Suffix:
Gender:F
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:PO BOX 31266
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68131-0266
Mailing Address - Country:US
Mailing Address - Phone:402-249-6136
Mailing Address - Fax:402-502-6823
Practice Address - Street 1:4908 CASS ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68132-2913
Practice Address - Country:US
Practice Address - Phone:402-249-6136
Practice Address - Fax:402-502-6823
Is Sole Proprietor?:No
Enumeration Date:2006-05-06
Last Update Date:2020-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE18749207RG0300X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1962451260Medicaid
NE10026724400Medicaid
NE1962451260Medicaid