Provider Demographics
NPI:1104976802
Name:KELLER, KENNETH (MD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:
Last Name:KELLER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 E BEAVER AVE
Mailing Address - Street 2:
Mailing Address - City:FORT MORGAN
Mailing Address - State:CO
Mailing Address - Zip Code:80701-3103
Mailing Address - Country:US
Mailing Address - Phone:970-542-1707
Mailing Address - Fax:970-542-1708
Practice Address - Street 1:220 E BEAVER AVE
Practice Address - Street 2:
Practice Address - City:FORT MORGAN
Practice Address - State:CO
Practice Address - Zip Code:80701-3103
Practice Address - Country:US
Practice Address - Phone:970-542-1707
Practice Address - Fax:970-542-1708
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-12
Last Update Date:2012-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO36926207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
COG73237Medicare UPIN