Healthcare Provider Details

I. General information

NPI: 1316203193
Provider Name (Legal Business Name): ANDREA L. KAELIN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/06/2012
Last Update Date: 05/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4881 SUGAR MAPLE DR
WRIGHT PATTERSON AFB OH
45433-5529
US

IV. Provider business mailing address

3535 SOUTHERN BLVD.
KETTERING OH
45429-1221
US

V. Phone/Fax

Practice location:
  • Phone: 937-257-0770
  • Fax:
Mailing address:
  • Phone: 937-395-8839
  • Fax: 937-395-8387

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number0101257376
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: