Provider Demographics
NPI:1982645818
Name:BAIN, KELLY J (MD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:J
Last Name:BAIN
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 1:901 PATIENTS FIRST DR
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63090-4700
Mailing Address - Country:US
Mailing Address - Phone:636-239-4100
Mailing Address - Fax:636-390-4341
Practice Address - Street 1:901 PATIENTS FIRST DR
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:MO
Practice Address - Zip Code:63090-4700
Practice Address - Country:US
Practice Address - Phone:636-239-4100
Practice Address - Fax:636-390-4341
Is Sole Proprietor?:No
Enumeration Date:2006-06-10
Last Update Date:2014-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO101371207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
080121864OtherRAILROAD MEDICARE
MOP01134656OtherRAILROAD MEDICARE
MO203380738Medicaid
001012943Medicare PIN
MO152810030Medicare PIN
MO203380738Medicaid
080121864OtherRAILROAD MEDICARE