Basic Information
| Provider Information | |||||||||
| NPI: | 1295789535 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KELLER | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | ROBERT | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KELLER | ||||||||
| OtherFirstName: | MARK | ||||||||
| OtherMiddleName: | R | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 550 WHITE OAK ST | ||||||||
| Address2: | |||||||||
| City: | ASHEBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 272034710 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3366251360 | ||||||||
| FaxNumber: | 3366251889 | ||||||||
| Practice Location | |||||||||
| Address1: | 197 NC HIGHWAY 42 N STE B | ||||||||
| Address2: | |||||||||
| City: | ASHEBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 27203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3366252560 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/20/2006 | ||||||||
| LastUpdateDate: | 10/25/2020 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 30821 | NC | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207Q00000X | 30821 | NC | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 8948123 | 05 | NC | MEDICAID | 48123 | 01 | NC | BLUE CROSS | OTHER |