Basic Information
| Provider Information | |||||||||
| NPI: | 1639176472 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KELLER | ||||||||
| FirstName: | VERN | ||||||||
| MiddleName: | ANTOINE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 23666 | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392253666 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6012004749 | ||||||||
| FaxNumber: | 6012005929 | ||||||||
| Practice Location | |||||||||
| Address1: | 155 HOSPITAL DR STE 201 | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 705032852 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3372897999 | ||||||||
| FaxNumber: | 3372897998 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2005 | ||||||||
| LastUpdateDate: | 12/28/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208G00000X | ME114423 | FL | N | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) | 208G00000X | 22054 | MS | N | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) | 208G00000X | 021788 | LA | Y | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) |
ID Information
| ID | Type | State | Issuer | Description | 00084714 | 05 | MS | MEDICAID | 1977292 | 05 | LA | MEDICAID | P01303537 | 01 | MS | RAILROAD MEDICARE | OTHER | 330005703 | 01 | LA | RR MEDICARE | OTHER |