Healthcare Provider Details

I. General information

NPI: 1083640304
Provider Name (Legal Business Name): GARY A KELLER M.D. PH.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2006
Last Update Date: 08/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

417 STATE ST STE 421
BANGOR ME
04401-6639
US

IV. Provider business mailing address

43 WHITING HILL RD STE 300
BREWER ME
04412-1005
US

V. Phone/Fax

Practice location:
  • Phone: 207-973-5293
  • Fax: 207-973-5263
Mailing address:
  • Phone: 207-973-5035
  • Fax: 207-973-5042

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number012479
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: