Basic Information
| Provider Information | |||||||||
| NPI: | 1811091424 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KELLER | ||||||||
| FirstName: | MARTIN | ||||||||
| MiddleName: | S | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 CHILDRENS PL | ||||||||
| Address2: | STE 6110, MSC 8235-49-6110 | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631101002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3144546022 | ||||||||
| FaxNumber: | 3144542442 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 CHILDRENS PL | ||||||||
| Address2: | DIV SURG PED, STE 2A | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631101002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3144546022 | ||||||||
| FaxNumber: | 3144542442 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/12/2006 | ||||||||
| LastUpdateDate: | 08/02/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/02/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0120X | 106695 | MO | Y | Allopathic & Osteopathic Physicians | Surgery | Pediatric Surgery | 2086S0120X | 042-0015839 | VT | N | Allopathic & Osteopathic Physicians | Surgery | Pediatric Surgery |
ID Information
| ID | Type | State | Issuer | Description | 205096605 | 05 | MO | MEDICAID |