Basic Information
| Provider Information | |||||||||
| NPI: | 1164638391 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | KENNEDY KRIEGER CHILDREN'S HOSPITAL, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | KENNEDY KRIEGER INSTITUTE - EQUIPMENT | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | P.O. BOX 744865 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30374 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4439231886 | ||||||||
| FaxNumber: | 4439231875 | ||||||||
| Practice Location | |||||||||
| Address1: | 707 N. BROADWAY | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 21205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4439239200 | ||||||||
| FaxNumber: | 4439239405 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2007 | ||||||||
| LastUpdateDate: | 09/16/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | NEUMAN | ||||||||
| AuthorizedOfficialFirstName: | MIKE | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 4439231810 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/16/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332BC3200X | 30-036 | MD | Y | Suppliers | Durable Medical Equipment & Medical Supplies | Customized Equipment |
ID Information
| ID | Type | State | Issuer | Description | 091678100 | 05 | MD | MEDICAID |