Basic Information
Provider Information | |||||||||
NPI: | 1518129220 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CIRIGLIANO | ||||||||
FirstName: | MARY | ||||||||
MiddleName: | KENNEY | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | D.O. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | KENNEY | ||||||||
OtherFirstName: | MARY | ||||||||
OtherMiddleName: | ELIZABETH | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | D.O. | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 2101 E JEFFERSON ST | ||||||||
Address2: | KAISER PERMANENTE MEDICARE ENROLLMENT | ||||||||
City: | ROCKVILLE | ||||||||
State: | MD | ||||||||
PostalCode: | 208524908 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3018162424 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 4023 GUILFORD COLLEGE RD | ||||||||
Address2: |   | ||||||||
City: | GREENSBORO | ||||||||
State: | NC | ||||||||
PostalCode: | 274078052 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3368902040 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/25/2008 | ||||||||
LastUpdateDate: | 04/28/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/28/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | OT012488 | PA | N |   | Allopathic & Osteopathic Physicians | Family Medicine |   | 207Q00000X | H72623 | MD | N |   | Allopathic & Osteopathic Physicians | Family Medicine |   | 207Q00000X | 2014-01614 | NC | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 2014-01614 | 01 | NC | LICENSE | OTHER |