Basic Information
| Provider Information | |||||||||
| NPI: | 1659406064 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BAKER | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | IRGENS | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 PRESTIGE PL | ||||||||
| Address2: | SUITE 550 | ||||||||
| City: | MIAMISBURG | ||||||||
| State: | OH | ||||||||
| PostalCode: | 453423794 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9377522306 | ||||||||
| FaxNumber: | 9375227626 | ||||||||
| Practice Location | |||||||||
| Address1: | 2449 ROSS MILLVILLE RD | ||||||||
| Address2: | SUITE B50 | ||||||||
| City: | HAMILTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 450138951 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5137376068 | ||||||||
| FaxNumber: | 5137376681 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/23/2007 | ||||||||
| LastUpdateDate: | 11/19/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/19/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 34.009213 | OH | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2956654 | 05 | OH | MEDICAID |