Provider Demographics
NPI:1043367345
Name:KENNETH A. GELLER, MD A PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:KENNETH A. GELLER, MD A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:GELLER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:323-669-4145
Mailing Address - Street 1:4650 W SUNSET BLVD
Mailing Address - Street 2:CHLA, DIVISION OF OTOLARYNGOLOGY, MS #58
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90027-6062
Mailing Address - Country:US
Mailing Address - Phone:323-669-4145
Mailing Address - Fax:323-664-7327
Practice Address - Street 1:4650 W SUNSET BLVD
Practice Address - Street 2:CHLA, DIVISION OF OTOLARYNGOLOGY, MS #58
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90027-6062
Practice Address - Country:US
Practice Address - Phone:323-669-4145
Practice Address - Fax:323-664-7327
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG26159174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G261590Medicaid
CAA42923Medicare UPIN