MEDICARE: VERN ANTOINE 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	208G00000X	Thoracic Surgery (Cardiothoracic Vascular Surgery) Physician	ME114423	FL
2	208G00000X	Thoracic Surgery (Cardiothoracic Vascular Surgery) Physician	22054	MS
3	208G00000X	Thoracic Surgery (Cardiothoracic Vascular Surgery) Physician	021788	LA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	P01303537	OTHER	MS	RAILROAD MEDICARE
4	330005703	OTHER	LA	RR MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1639176472
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VERN ANTOINE KELLER MD

Provider Business Mailing Address
First Line	:	PO BOX 23666
Second Line	:
City	:	JACKSON
State	:	MS
Zip	:	39225-3666
Country	:	US
Telephone Number	:	601-200-4749
Fax Number	:	601-200-5929

Provider Business Practice Location Address
First Line	:	155 HOSPITAL DR STE 201
Second Line	:
City	:	LAFAYETTE
State	:	LA
Zip	:	70503-2852
Country	:	US
Telephone Number	:	337-289-7999
Fax Number	:	337-289-7998

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

Provider Enumeration Date	:	07/07/2005
Last Update Date	:	12/28/2021

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Directions to “ VERN ANTOINE KELLER MD” Practice Location

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