Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207R00000X | Internist | 02.0005602 | VT |
Y | 111NI0900X | Internist | 02.0005602 | VT |
N | 207RA0401X | Internist - Addiction Medicine | 042.0005602 | VT |
NPI | 1124039128 |
---|---|
Provider Name | Marc I Keller |
First Address | Burlington, VT 05401-3900 |
Second Address | Burlington, VT 05401 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 11/08/2006 |
Last Update Date | 01/04/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0004733 | (05) | VT |
30010121 | (05) | NH |
65469 | (02) |