Provider Demographics
NPI:1295789535
Name:KELLER, MARK ROBERT (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:ROBERT
Last Name:KELLER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:MARK
Other - Middle Name:R
Other - Last Name:KELLER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:550 WHITE OAK ST
Mailing Address - Street 2:
Mailing Address - City:ASHEBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27203-4710
Mailing Address - Country:US
Mailing Address - Phone:336-625-1360
Mailing Address - Fax:336-625-1889
Practice Address - Street 1:197 NC HIGHWAY 42 N STE B
Practice Address - Street 2:
Practice Address - City:ASHEBORO
Practice Address - State:NC
Practice Address - Zip Code:27203
Practice Address - Country:US
Practice Address - Phone:336-625-2560
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2020-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC30821207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8948123Medicaid
NC48123OtherBLUE CROSS
NC48123OtherBLUE CROSS
NCE54600Medicare UPIN