Basic Information
| Provider Information | |||||||||
| NPI: | 1164466421 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KELLER | ||||||||
| FirstName: | SEAN | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | DR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 250 N SHADELAND AVE | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462194959 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 13100 E 136TH ST | ||||||||
| Address2: | STE 1200 | ||||||||
| City: | FISHERS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 460379417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3176783100 | ||||||||
| FaxNumber: | 3176783108 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2006 | ||||||||
| LastUpdateDate: | 11/25/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/25/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 01053956 | IN | N | Allopathic & Osteopathic Physicians | Pediatrics | 207R00000X | 01053956 | IN | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200449180 | 05 | IN | MEDICAID |