Healthcare Provider Details

I. General information

NPI: 1700845195
Provider Name (Legal Business Name): ALEXANDER P. KELLER IV M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2006
Last Update Date: 09/24/2024
Certification Date: 09/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

88 MDG/SGH
WRIGHT-PATTERSON AFB OH
45433
US

IV. Provider business mailing address

5519 COTTONROSE DR
DAYTON OH
45431-1579
US

V. Phone/Fax

Practice location:
  • Phone: 937-938-2758
  • Fax:
Mailing address:
  • Phone: 706-714-6878
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License NumberS7471
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number058258
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License NumberS7471
License Number StateTX
# 4
Primary TaxonomyN
Taxonomy Code2083A0100X
TaxonomyAerospace Medicine Physician
License Number058258
License Number StateGA
# 5
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number35.150633
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: