MEDICARE: JOHN MARK KELLER PTA

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	225200000X	Physical Therapy Assistant	40QB00359700	NJ

General Provider Information

NPI Number	:	1659145209
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHN MARK KELLER PTA

Provider Business Mailing Address
First Line	:	204 ARK RD
Second Line	:
City	:	MOUNT LAUREL
State	:	NJ
Zip	:	08054-3100
Country	:	US
Telephone Number	:	856-553-1151
Fax Number	:

Provider Business Practice Location Address
First Line	:	16 OVERHILL RD
Second Line	:
City	:	MOUNT LAUREL
State	:	NJ
Zip	:	08054-2045
Country	:	US
Telephone Number	:	609-757-2527
Fax Number	:

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

Provider Enumeration Date	:	11/13/2023
Last Update Date	:	11/13/2023

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