MEDICARE: SHANE EDWARD KELLER MD PA

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	207Q00000X	Family Medicine Physician	L8393	TX

General Provider Information

NPI Number	:	1407870959
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SHANE EDWARD KELLER MD PA

Provider Business Mailing Address
First Line	:	PO BOX 4374
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77210-4374
Country	:	US
Telephone Number	:	512-252-1505
Fax Number	:	512-252-1506

Provider Business Practice Location Address
First Line	:	505 W LOUIS HENNA BLVD STE 100
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78728-1702
Country	:	US
Telephone Number	:	512-252-1505
Fax Number	:	512-252-1506

Authorized Official
Title or Position	:	PRESIDENT
Name	:	SHANE EDWARD KELLER
Credential	:	MD
Telephone Number	:	512-252-1505

Provider Enumeration Date	:	07/27/2006
Last Update Date	:	12/10/2019

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