Provider Demographics
NPI:1730207820
Name:KELLER, KELLI MARIE (MD)
Entity type:Individual
Prefix:
First Name:KELLI
Middle Name:MARIE
Last Name:KELLER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24600 W. 127TH ST
Mailing Address - Street 2:STE B325
Mailing Address - City:PLAINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60585-9502
Mailing Address - Country:US
Mailing Address - Phone:815-731-9100
Mailing Address - Fax:815-731-9110
Practice Address - Street 1:24600 W 127TH ST
Practice Address - Street 2:STE B325
Practice Address - City:PLAINFIELD
Practice Address - State:IL
Practice Address - Zip Code:60585-9502
Practice Address - Country:US
Practice Address - Phone:815-731-9100
Practice Address - Fax:815-731-9110
Is Sole Proprietor?:No
Enumeration Date:2007-03-27
Last Update Date:2009-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL361170642084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL2220936OtherBCBS
IL036117064 2Medicaid
IL036117064 2Medicaid