Basic Information
| Provider Information | |||||||||
| NPI: | 1619075926 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KENNEDY KRIEGER CHILDREN'S HOSPITAL, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | KENNEDY KRIEGER INSTITUTE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 45944 | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212975944 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4439231886 | ||||||||
| FaxNumber: | 4439231875 | ||||||||
| Practice Location | |||||||||
| Address1: | 707 N BROADWAY | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212051832 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4439231870 | ||||||||
| FaxNumber: | 4439239405 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2006 | ||||||||
| LastUpdateDate: | 03/08/2022 | ||||||||
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| AuthorizedOfficialLastName: | BADIE | ||||||||
| AuthorizedOfficialFirstName: | LISA | ||||||||
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| AuthorizedOfficialTitleorPosition: | AVP, APPLICATION SUPPORT | ||||||||
| AuthorizedOfficialTelephone: | 4439231812 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 03/08/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 281PC2000X | N | Hospitals | Chronic Disease Hospital | Children | 291U00000X | 802 | MD | N | Laboratories | Clinical Medical Laboratory | 282E00000X | 30-036 | MD | N | Hospitals | Long Term Care Hospital | 283Q00000X | N | Hospitals | Psychiatric Hospital | 283XC2000X | N | Hospitals | Rehabilitation Hospital | Children | 284300000X | 30-036 | MD | N | Hospitals | Special Hospital | 261QD1600X | 30036 | MD | Y | Ambulatory Health Care Facilities | Clinic/Center | Developmental Disabilities |
ID Information
| ID | Type | State | Issuer | Description | 59351301 | 01 | MD | BLUE CROSS OF MARYLAND | OTHER | 955675300 | 05 | MD | MEDICAID | MD9 | 01 | MD | BLUE CROSS FEDERAL | OTHER |