Healthcare Provider Details

I. General information

NPI: 1821481912
Provider Name (Legal Business Name): I. BASIL KELLER, M.D.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/12/2015
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1850 37TH ST SUITE C
VERO BEACH FL
32960-4856
US

IV. Provider business mailing address

PO BOX 1449
VERO BEACH FL
32961-1449
US

V. Phone/Fax

Practice location:
  • Phone: 772-569-9611
  • Fax: 772-569-9615
Mailing address:
  • Phone: 772-569-9611
  • Fax: 772-569-9615

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License NumberME19360
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberME19360
License Number StateFL

VIII. Authorized Official

Name: DR. IRVIN BASIL KELLER
Title or Position: SOLE PROPRIETOR
Credential: M.D.
Phone: 772-569-9611