Healthcare Provider Details

I. General information

NPI: 1588705537
Provider Name (Legal Business Name): KENNETH RONALD KELLER D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/12/2007
Last Update Date: 06/07/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2449 ROSS MILLVILLE RD
HAMILTON OH
45013-8951
US

IV. Provider business mailing address

27 E DIXON AVE
DAYTON OH
45419-3438
US

V. Phone/Fax

Practice location:
  • Phone: 513-856-7360
  • Fax:
Mailing address:
  • Phone: 937-643-9032
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number34.003913
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number34 003913
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code2083X0100X
TaxonomyOccupational Medicine Physician
License Number34 003913
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: