Healthcare Provider Details

I. General information

NPI: 1962459875
Provider Name (Legal Business Name): JEFFREY L KELLER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2006
Last Update Date: 11/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

90 S BEDFORD RD CARE MOUNT MEDICAL PC
MOUNT KISCO NY
10549-3412
US

IV. Provider business mailing address

110 S BEDFORD RD CARE MOUNT MEDICAL PC
MOUNT KISCO NY
10549-3446
US

V. Phone/Fax

Practice location:
  • Phone: 914-241-1050
  • Fax: 914-242-1516
Mailing address:
  • Phone: 914-241-1050
  • Fax: 914-242-1516

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number188631
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207YP0228X
TaxonomyPediatric Otolaryngology Physician
License Number188631
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License Number188631
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: