Provider Demographics
NPI:1982805511
Name:CARY S KELLER MD PC
Entity Type:Organization
Organization Name:CARY S KELLER MD PC
Other - Org Name:SPORTSMEDICINE FAIRBANKS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:S
Authorized Official - Last Name:DEAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-451-6561
Mailing Address - Street 1:751 OLD RICHARDSON HWY
Mailing Address - Street 2:SUITE 200
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99701-7813
Mailing Address - Country:US
Mailing Address - Phone:907-451-6561
Mailing Address - Fax:907-451-4847
Practice Address - Street 1:751 OLD RICHARDSON HWY
Practice Address - Street 2:SUITE 200
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-7813
Practice Address - Country:US
Practice Address - Phone:907-451-6561
Practice Address - Fax:907-451-4847
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK38793332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMDG202Medicaid
AKMDG202Medicaid