MEDICARE: MICHAEL I KELLER M.D. INC

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	174400000X	Specialist	G28715	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
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	:	1861593063
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MICHAEL I KELLER M.D. INC

Provider Business Mailing Address
First Line	:	3633 CAMINO DEL RIO S
Second Line	:	#300
City	:	SAN DIEGO
State	:	CA
Zip	:	92108-4011
Country	:	US
Telephone Number	:	619-287-9730
Fax Number	:	619-287-4516

Provider Business Practice Location Address
First Line	:	3633 CAMINO DEL RIO S
Second Line	:	#300
City	:	SAN DIEGO
State	:	CA
Zip	:	92108-4011
Country	:	US
Telephone Number	:	619-287-9730
Fax Number	:	619-287-4516

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. MICHAEL IRA KELLER
Credential	:	M.D.
Telephone Number	:	619-287-9730

Provider Enumeration Date	:	09/26/2006
Last Update Date	:	08/27/2010

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