Provider Demographics
NPI:1093793416
Name:BAENDER, KELLI INGRAM (MD)
Entity Type:Individual
Prefix:DR
First Name:KELLI
Middle Name:INGRAM
Last Name:BAENDER
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 1:3379 PEACHTREE RD. NE
Mailing Address - Street 2:SUITE 500
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30326-1418
Mailing Address - Country:US
Mailing Address - Phone:404-355-5484
Mailing Address - Fax:404-355-5787
Practice Address - Street 1:3379 PEACHTREE RD. NE
Practice Address - Street 2:SUITE 500
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30326-1418
Practice Address - Country:US
Practice Address - Phone:404-355-5484
Practice Address - Fax:404-355-5787
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-05
Last Update Date:2014-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA60105207N00000X, 207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ86080015085259A972OtherTRIWEST
AZP00231283OtherRAILROAD MEDICARE
AZ894057Medicaid
I21981Medicare UPIN
GA511I070048Medicare PIN
AZZ100160Medicare PIN