Healthcare Provider Details

I. General information

NPI: 1790762110
Provider Name (Legal Business Name): MARK L KELLER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/28/2005
Last Update Date: 07/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2115 N KANSAS AVE MIDWEST EAR NOSE & THROAT SPECIALISTS PC
HASTINGS NE
68901-2644
US

IV. Provider business mailing address

2115 N KANSAS AVE MIDWEST EAR NOSE & THROAT SPECIALISTS PC
HASTINGS NE
68901-2644
US

V. Phone/Fax

Practice location:
  • Phone: 402-463-2431
  • Fax: 402-463-2486
Mailing address:
  • Phone: 402-463-2431
  • Fax: 402-463-2486

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number21286
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: