MEDICARE: SHANE E KELLER MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	L8393	TX

General Provider Information

NPI Number	:	1194768911
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHANE E KELLER MD

Provider Business Mailing Address
First Line	:	PO BOX 4374
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77210-4374
Country	:	US
Telephone Number	:	512-252-1505
Fax Number	:	512-252-1506

Provider Business Practice Location Address
First Line	:	505 W LOUIS HENNA BLVD
Second Line	:	STE 100
City	:	AUSTIN
State	:	TX
Zip	:	78728-1702
Country	:	US
Telephone Number	:	512-252-1505
Fax Number	:	512-252-1506

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/13/2006
Last Update Date	:	12/10/2019

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