MEDICARE: DR. CHARLES KELLER III MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2080P0207X	Pediatric Hematology & Oncology Physician	360961-1205	UT

General Provider Information

NPI Number	:	1053883181
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CHARLES KELLER III MD

Provider Business Mailing Address
First Line	:	4919 SW SEYMOUR CT
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97221-3040
Country	:	US
Telephone Number	:	801-232-8038
Fax Number	:

Provider Business Practice Location Address
First Line	:	2198 S YVONNE RD #344
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84121
Country	:	US
Telephone Number	:	801-232-8038
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/31/2018
Last Update Date	:	12/31/2018

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