Provider Demographics
NPI:1063492478
Name:BURGHARD, KELLY L (MD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:L
Last Name:BURGHARD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7335 YANKEE RD STE 201
Mailing Address - Street 2:
Mailing Address - City:LIBERTY TOWNSHIP
Mailing Address - State:OH
Mailing Address - Zip Code:45044-1253
Mailing Address - Country:US
Mailing Address - Phone:513-564-6818
Mailing Address - Fax:513-564-6819
Practice Address - Street 1:7335 YANKEE RD STE 201
Practice Address - Street 2:
Practice Address - City:LIBERTY TOWNSHIP
Practice Address - State:OH
Practice Address - Zip Code:45044-1253
Practice Address - Country:US
Practice Address - Phone:513-564-6818
Practice Address - Fax:513-564-6819
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-20
Last Update Date:2020-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.082204207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0059727Medicaid
OHH383670Medicare PIN
OH0059727Medicaid
OHBU410779Medicare ID - Type Unspecified