Provider Demographics
NPI:1861593063
Name:MICHAEL I KELLER M.D. INC
Entity type:Organization
Organization Name:MICHAEL I KELLER M.D. INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:IRA
Authorized Official - Last Name:KELLER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:619-287-9730
Mailing Address - Street 1:3633 CAMINO DEL RIO S
Mailing Address - Street 2:#300
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-4011
Mailing Address - Country:US
Mailing Address - Phone:619-287-9730
Mailing Address - Fax:619-287-4516
Practice Address - Street 1:3633 CAMINO DEL RIO S
Practice Address - Street 2:#300
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-4011
Practice Address - Country:US
Practice Address - Phone:619-287-9730
Practice Address - Fax:619-287-4516
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-26
Last Update Date:2010-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG28715174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0104521Medicaid
CAGR0104522Medicaid
CAGR0104523Medicaid
CAGR0104520Medicaid
CAW6392Medicare PIN
CAGR0104523Medicaid
CAGR0104520Medicaid