MEDICARE: DR. KELLY J BAEK MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207VE0102X	Reproductive Endocrinology Physician	25MA08120900	NJ
2	207VE0102X	Reproductive Endocrinology Physician	C53761	CA

General Provider Information

NPI Number	:	1144385212
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KELLY J BAEK MD

Provider Business Mailing Address
First Line	:	11818 WILSHIRE BLVD
Second Line	:	SUITE 300
City	:	LOS ANGELES
State	:	CA
Zip	:	90025-6646
Country	:	US
Telephone Number	:	310-828-4008
Fax Number	:	310-828-3310

Provider Business Practice Location Address
First Line	:	11818 WILSHIRE BLVD
Second Line	:	SUITE 300
City	:	LOS ANGELES
State	:	CA
Zip	:	90025-6646
Country	:	US
Telephone Number	:	310-828-4008
Fax Number	:	310-828-3310

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/27/2006
Last Update Date	:	01/08/2014

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Directions to “ DR. KELLY J BAEK MD” Practice Location

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