Provider Demographics
NPI:1982743159
Name:KELLER, ROMAN HYSTAD (DO)
Entity type:Individual
Prefix:
First Name:ROMAN
Middle Name:HYSTAD
Last Name:KELLER
Suffix:
Gender:M
Credentials:DO
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 7366
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56302-7366
Mailing Address - Country:US
Mailing Address - Phone:320-257-7787
Mailing Address - Fax:320-257-5596
Practice Address - Street 1:1990 CONNECTICUT AVE S
Practice Address - Street 2:
Practice Address - City:SARTELL
Practice Address - State:MN
Practice Address - Zip Code:56377-2554
Practice Address - Country:US
Practice Address - Phone:320-257-5595
Practice Address - Fax:320-257-5596
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2011-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK44202085R0202X
MN526802085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1982743159Medicaid
MN300005566Medicare PIN