Healthcare Provider Details

I. General information

NPI: 1407870876
Provider Name (Legal Business Name): BRETT L. KELLER D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/27/2006
Last Update Date: 10/04/2022
Certification Date: 10/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1505 EASTLAND DR SUITE 220
BLOOMINGTON IL
61701-3534
US

IV. Provider business mailing address

1505 EASTLAND DR SUITE 220
BLOOMINGTON IL
61701-3534
US

V. Phone/Fax

Practice location:
  • Phone: 309-662-2278
  • Fax: 309-663-2956
Mailing address:
  • Phone: 309-662-2278
  • Fax: 309-663-2956

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number036110898
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: