MEDICARE: KIMBERLY ANNE KELLER DO

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	207R00000X	Internal Medicine Physician	OS10013	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	04125	OTHER	FL	BCBS OF FL
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1366481483
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KIMBERLY ANNE KELLER DO

Provider Business Mailing Address
First Line	:	125 FLORIDA MEMORIAL PKWY
Second Line	:	SUITE 2600
City	:	NEW SMYRNA BEACH
State	:	FL
Zip	:	32168-9356
Country	:	US
Telephone Number	:	386-409-6864
Fax Number	:	386-409-6813

Provider Business Practice Location Address
First Line	:	125 FLORIDA MEMORIAL PKWY
Second Line	:	SUITE 2600
City	:	NEW SMYRNA BEACH
State	:	FL
Zip	:	32168-9356
Country	:	US
Telephone Number	:	386-409-6864
Fax Number	:	386-409-6813

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

Provider Enumeration Date	:	06/05/2006
Last Update Date	:	10/22/2015

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Directions to “ KIMBERLY ANNE KELLER DO” Practice Location

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