Provider Demographics
NPI:1639402167
Name:KELLER, KIM DUANE (BC-HIS)
Entity type:Individual
Prefix:MR
First Name:KIM
Middle Name:DUANE
Last Name:KELLER
Suffix:
Gender:M
Credentials:BC-HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1549 POTOMAC AVE
Mailing Address - Street 2:
Mailing Address - City:HAGERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21742-2930
Mailing Address - Country:US
Mailing Address - Phone:301-797-2344
Mailing Address - Fax:240-625-9449
Practice Address - Street 1:1549 POTOMAC AVE
Practice Address - Street 2:
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21742-2930
Practice Address - Country:US
Practice Address - Phone:301-797-2344
Practice Address - Fax:240-625-9449
Is Sole Proprietor?:No
Enumeration Date:2009-09-16
Last Update Date:2016-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD1581174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist