Healthcare Provider Details

I. General information

NPI: 1477843282
Provider Name (Legal Business Name): KEITH LINCOLN KELLER M.D., R.PH.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/13/2011
Last Update Date: 04/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

IHS PINE RIDGE SERVICE UNIT HWY 18
PINE RIDGE SD
57770
US

IV. Provider business mailing address

PO BOX 203
PINE RIDGE SD
57770-0203
US

V. Phone/Fax

Practice location:
  • Phone: 605-867-3195
  • Fax:
Mailing address:
  • Phone: 402-238-4913
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number16677
License Number StateNE
# 2
Primary TaxonomyN
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number11551
License Number StateCO
# 3
Primary TaxonomyN
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number10573
License Number StateNE
# 4
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number145651-1701
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: