Basic Information
| Provider Information | |||||||||
| NPI: | 1881824795 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KREMER | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 250 N SHADELAND AVE | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462194959 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 3333 BURNET AVE # MLC2015 | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452293026 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5136364222 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2009 | ||||||||
| LastUpdateDate: | 02/02/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/02/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0402X | 55962 | KY | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology with Special Qualifications in Child Neurology | 2084N0402X | 35.126172 | OH | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology with Special Qualifications in Child Neurology | 2084N0402X | 01077138A | IN | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology with Special Qualifications in Child Neurology |
ID Information
| ID | Type | State | Issuer | Description | 201304070 | 05 | IN | MEDICAID |