Basic Information
| Provider Information | |||||||||
| NPI: | 1447236922 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MELVIN | ||||||||
| FirstName: | KELLI | ||||||||
| MiddleName: | P | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1012 E CENTRAL AVE | ||||||||
| Address2: | |||||||||
| City: | MIAMISBURG | ||||||||
| State: | OH | ||||||||
| PostalCode: | 453422556 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9378660741 | ||||||||
| FaxNumber: | 9378668861 | ||||||||
| Practice Location | |||||||||
| Address1: | 3033 KETTERING BLVD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | MORAINE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454391962 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372932133 | ||||||||
| FaxNumber: | 9378668861 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/16/2005 | ||||||||
| LastUpdateDate: | 06/22/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 35082342 | OH | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 8234201 | 01 | OH | HUMANA | OTHER | 7082442 | 01 | OH | AETNA | OTHER | 2461232 | 05 | OH | MEDICAID | 283160 | 01 | OH | AMERIGROUP | OTHER |