Basic Information
| Provider Information | |||||||||
| NPI: | 1740713254 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MAYRAND | ||||||||
| FirstName: | KELSEY | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2261 PHILADELPHIA DR | ||||||||
| Address2: | |||||||||
| City: | DAYTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454061814 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9377344141 | ||||||||
| FaxNumber: | 9372777249 | ||||||||
| Practice Location | |||||||||
| Address1: | 1244 MEADOW BRIDGE DR STE 100 | ||||||||
| Address2: | |||||||||
| City: | BEAVERCREEK | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454346388 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372087600 | ||||||||
| FaxNumber: | 9372087620 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2017 | ||||||||
| LastUpdateDate: | 10/26/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/26/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 35.139593 | OH | Y | Allopathic & Osteopathic Physicians | Family Medicine | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program |
ID Information
| ID | Type | State | Issuer | Description | 0405964 | 05 | OH | MEDICAID |