Provider Demographics
NPI:1659406064
Name:BAKER, KELLY IRGENS (DO)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:IRGENS
Last Name:BAKER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1 PRESTIGE PL
Mailing Address - Street 2:SUITE 550
Mailing Address - City:MIAMISBURG
Mailing Address - State:OH
Mailing Address - Zip Code:45342-3794
Mailing Address - Country:US
Mailing Address - Phone:937-752-2306
Mailing Address - Fax:937-522-7626
Practice Address - Street 1:2449 ROSS MILLVILLE RD
Practice Address - Street 2:SUITE B50
Practice Address - City:HAMILTON
Practice Address - State:OH
Practice Address - Zip Code:45013-8951
Practice Address - Country:US
Practice Address - Phone:513-737-6068
Practice Address - Fax:513-737-6681
Is Sole Proprietor?:No
Enumeration Date:2007-02-23
Last Update Date:2020-11-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OH34.009213207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2956654Medicaid
OH2956654Medicaid
OHH085571Medicare PIN