Provider Demographics
NPI:1013164086
Name:KELLER, MICHAEL JAMES (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JAMES
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 1:1269 N WOLCOTT AVE APT 2R
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-3895
Mailing Address - Country:US
Mailing Address - Phone:319-400-1305
Mailing Address - Fax:
Practice Address - Street 1:800 BIESTERFIELD RD
Practice Address - Street 2:SUITE 510
Practice Address - City:ELK GROVE VILLAGE
Practice Address - State:IL
Practice Address - Zip Code:60007-3361
Practice Address - Country:US
Practice Address - Phone:847-981-3660
Practice Address - Fax:847-956-5108
Is Sole Proprietor?:No
Enumeration Date:2008-08-21
Last Update Date:2021-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036123136207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036134102Medicaid