=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174787162
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JESSE WADE KELLER MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/18/2008
-----------------------------------------------------
Last Update Date | 09/11/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 915 N GRAND BLVD
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63106-1621
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-651-4100
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7 LADUE LN
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63124-1632
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-706-2601
-----------------------------------------------------
Fax | 415-706-2601
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RX0202X
-----------------------------------------------------
Taxonomy Name | Medical Oncology Physician
-----------------------------------------------------
License Number | 2013011512
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------