Basic Information
| Provider Information | |||||||||
| NPI: | 1538124888 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KELLER | ||||||||
| FirstName: | BOWEN | ||||||||
| MiddleName: | ELIOT | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 550 OSBORNE RD NE | ||||||||
| Address2: | |||||||||
| City: | FRIDLEY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554322718 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7635725710 | ||||||||
| FaxNumber: | 7635713008 | ||||||||
| Practice Location | |||||||||
| Address1: | 550 OSBORNE RD NE | ||||||||
| Address2: | |||||||||
| City: | FRIDLEY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554322718 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7632365000 | ||||||||
| FaxNumber: | 7632363524 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/19/2006 | ||||||||
| LastUpdateDate: | 03/11/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 03/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 40560 | MN | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 55Q07KE | 01 | MN | BCBS OF MN | OTHER | 5366669 | 01 | MN | AETNA | OTHER | 779466 | 01 | MN | AMERICA'S PPO | OTHER | 124494 | 01 | MN | UCARE | OTHER | 0413830 | 01 | MN | MEDICA | OTHER | 1017337 | 01 | MN | PREFERRED ONE | OTHER | HP26738 | 01 | MN | HEALTHPARTNERS | OTHER | 476817500 | 05 | MN | MEDICAID |