Provider Demographics
NPI:1932200201
Name:KELTON MEDICAL, LLC
Entity Type:Organization
Organization Name:KELTON MEDICAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:A
Authorized Official - Last Name:KELTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:410-787-4908
Mailing Address - Street 1:PO BOX 25757
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21224-0457
Mailing Address - Country:US
Mailing Address - Phone:410-787-4908
Mailing Address - Fax:
Practice Address - Street 1:301 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21061-5803
Practice Address - Country:US
Practice Address - Phone:410-787-4908
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-26
Last Update Date:2008-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD45018207L00000X
MDD00450182083P0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2083P0011XAllopathic & Osteopathic PhysiciansPreventive MedicineUndersea and Hyperbaric MedicineGroup - Multi-Specialty
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDDG4495OtherRAILROAD MEDICARE GROUP #
MD431303800Medicaid
MDF466OtherBLUECHOICE MARYLAND #
MDLZ42KEOtherCAREFIRST, MARLYAND GROUP
MDF466OtherBLUECHOICE MARYLAND #
MD138MMedicare PIN