Healthcare Provider Details

I. General information

NPI: 1003100082
Provider Name (Legal Business Name): CHAD ROBERT KELLER D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2011
Last Update Date: 11/17/2020
Certification Date: 11/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4439 STATE ROUTE 159 STE G70
CHILLICOTHEE OH
45601-7203
US

IV. Provider business mailing address

90 JACKSON PIKE
GALLIPOLIS OH
45631-1560
US

V. Phone/Fax

Practice location:
  • Phone: 407-794-3987
  • Fax:
Mailing address:
  • Phone: 740-589-3100
  • Fax: 740-589-3123

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number34.011623
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: