Healthcare Provider Details

I. General information

NPI: 1376744599
Provider Name (Legal Business Name): NOAH E KELLER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: JENNIFER E KELLER

II. Dates (important events)

Enumeration Date: 05/29/2007
Last Update Date: 03/30/2022
Certification Date: 03/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 EUREKA RD
ROSEVILLE CA
95661-3027
US

IV. Provider business mailing address

1800 HARRISON ST FL 7
OAKLAND CA
94612-3466
US

V. Phone/Fax

Practice location:
  • Phone: 916-784-4000
  • Fax: 877-738-4262
Mailing address:
  • Phone: 510-625-2856
  • Fax: 877-738-4262

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number2007-01217
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2086S0120X
TaxonomyPediatric Surgery Physician
License NumberA117557
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: