Provider Demographics
NPI:1215994959
Name:KELLER, BRIAN KEITH (MD)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:KEITH
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:PO BOX 530062
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30353-0062
Mailing Address - Country:US
Mailing Address - Phone:843-695-6071
Mailing Address - Fax:843-569-5879
Practice Address - Street 1:435 N CEDAR ST
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29483-6407
Practice Address - Country:US
Practice Address - Phone:843-873-1592
Practice Address - Fax:843-507-8284
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2021-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC18014207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC080163302OtherMEDICARE RAIL ROAD
SC180146Medicaid
SC180146Medicaid
SCG229607006Medicare PIN
SCSC21207126Medicare PIN
SC080163302OtherMEDICARE RAIL ROAD