Healthcare Provider Details

I. General information

NPI: 1265497515
Provider Name (Legal Business Name): RICHARD L KELLER II MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2006
Last Update Date: 09/15/2021
Certification Date: 09/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

285 W 12TH ST STE 102
PERU IN
46970-1654
US

IV. Provider business mailing address

6920 POINTE INVERNESS WAY STE 200
FORT WAYNE IN
46804-7934
US

V. Phone/Fax

Practice location:
  • Phone: 765-472-4356
  • Fax: 260-479-2927
Mailing address:
  • Phone: 765-472-4356
  • Fax: 260-479-2927

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number01051573A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: