Provider Demographics
NPI:1649543323
Name:KELLER SKIN & CANCER CARE PC
Entity type:Organization
Organization Name:KELLER SKIN & CANCER CARE PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WADE
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:KELLER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:208-939-6227
Mailing Address - Street 1:1605 E RIVERSIDE DR
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-6237
Mailing Address - Country:US
Mailing Address - Phone:208-939-6227
Mailing Address - Fax:208-939-6442
Practice Address - Street 1:1605 E RIVERSIDE DRIVE
Practice Address - Street 2:
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616
Practice Address - Country:US
Practice Address - Phone:208-939-6227
Practice Address - Fax:208-939-6442
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-11
Last Update Date:2022-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDO-0559207N00000X
207ND0101X, 207NS0135X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Single Specialty
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Single Specialty