Provider Demographics
NPI:1245306810
Name:NATHANIEL KELLER MD PA
Entity type:Organization
Organization Name:NATHANIEL KELLER MD PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:NATHANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:KELLER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:954-792-0772
Mailing Address - Street 1:7469 NW 4TH ST
Mailing Address - Street 2:
Mailing Address - City:PLANTATION
Mailing Address - State:FL
Mailing Address - Zip Code:33317-2216
Mailing Address - Country:US
Mailing Address - Phone:954-792-0772
Mailing Address - Fax:954-792-1221
Practice Address - Street 1:7469 NW 4TH ST
Practice Address - Street 2:
Practice Address - City:PLANTATION
Practice Address - State:FL
Practice Address - Zip Code:33317-2216
Practice Address - Country:US
Practice Address - Phone:954-792-0772
Practice Address - Fax:954-792-1221
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-27
Last Update Date:2007-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME879052084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL74806Medicare ID - Type Unspecified
H28266Medicare UPIN