Provider Demographics
NPI:1578688552
Name:AMY M. KELLER OD PC
Entity type:Organization
Organization Name:AMY M. KELLER OD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:AMY
Authorized Official - Middle Name:M
Authorized Official - Last Name:KELLER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:231-832-3133
Mailing Address - Street 1:115 W UPTON AVENUE
Mailing Address - Street 2:
Mailing Address - City:REED CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49677-1129
Mailing Address - Country:US
Mailing Address - Phone:231-832-3133
Mailing Address - Fax:231-832-1417
Practice Address - Street 1:115 W UPTON AVENUE
Practice Address - Street 2:
Practice Address - City:REED CITY
Practice Address - State:MI
Practice Address - Zip Code:49677-1129
Practice Address - Country:US
Practice Address - Phone:231-832-3133
Practice Address - Fax:231-832-1417
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:AMY M. KELLER OD PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-03-20
Last Update Date:2013-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAK003308152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2883730Medicaid
MI1336259761OtherDR. KELLER'S PERSONAL NPI
MI0N43890OtherMEDICARE ID
MI0289080001OtherADMINISTAR FEDERAL, INC
MI1184727612OtherDR. WILSON'S PERSONAL NPI
MI1184727612OtherDR. WILSON'S PERSONAL NPI
MI0N43890OtherMEDICARE ID