MEDICARE: DR. RICHARD KELLER M.D.

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	2085R0202X	Diagnostic Radiology Physician	145118-1205	UT

General Provider Information

NPI Number	:	1619292182
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RICHARD KELLER M.D.

Provider Business Mailing Address
First Line	:	1235 EAST 200 SOUTH #702
Second Line	:	1235 EAST 200 SOUTH #702
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84102-8410
Country	:	US
Telephone Number	:	801-355-9040
Fax Number	:

Provider Business Practice Location Address
First Line	:	1235 EAST 200 SOUTH #702
Second Line	:	1235 EAST 200 SOUTH #702
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84102-8410
Country	:	US
Telephone Number	:	801-355-9040
Fax Number	:

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

Provider Enumeration Date	:	03/29/2010
Last Update Date	:	03/29/2010

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