Basic Information
| Provider Information | |||||||||
| NPI: | 1871515783 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KENNEDY KRIEGER ASSOCIATES | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 744865 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303744865 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4439231886 | ||||||||
| FaxNumber: | 4439231875 | ||||||||
| Practice Location | |||||||||
| Address1: | 707 N BROADWAY | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212051832 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4439231070 | ||||||||
| FaxNumber: | 4439231875 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/24/2006 | ||||||||
| LastUpdateDate: | 04/03/2020 | ||||||||
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| AuthorizedOfficialLastName: | NEUMAN | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 4439231810 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | KENNEDY KRIEGER INSTITUTE | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | 04/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X | N | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty | 208000000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 168641100 | 05 | MD | MEDICAID | K631 | 01 | MD | BLUE CROSS MARYLAND | OTHER | F158 | 01 | MD | BLUE CROSS FEDERAL | OTHER |