Provider Demographics
NPI:1184770521
Name:I. BASIL KELLER, M.D.
Entity type:Organization
Organization Name:I. BASIL KELLER, M.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:IRVIN
Authorized Official - Middle Name:BASIL
Authorized Official - Last Name:KELLER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:772-569-6444
Mailing Address - Street 1:PO BOX 1449
Mailing Address - Street 2:
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32961-1449
Mailing Address - Country:US
Mailing Address - Phone:772-569-9611
Mailing Address - Fax:772-569-9615
Practice Address - Street 1:3790 7TH TER
Practice Address - Street 2:STE., 201
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32960-6552
Practice Address - Country:US
Practice Address - Phone:772-569-9611
Practice Address - Fax:772-569-9615
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-26
Last Update Date:2008-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL279265600Medicaid
FL05302AMedicare ID - Type Unspecified