Basic Information
| Provider Information | |||||||||
| NPI: | 1881800027 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | KENNEDY KRIEGER CHILDREN'S HOSPITAL, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | KENNEDY KRIEGER INTITUTE - ACUTE CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | P.O. BOX 744865 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30374 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4439231886 | ||||||||
| FaxNumber: | 4439231895 | ||||||||
| 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: | 09/14/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | NEUMAN | ||||||||
| AuthorizedOfficialFirstName: | MIKE | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 4439231810 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/14/2020 | ||||||||
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 | 284300000X | 30-036 | MD | N | Hospitals | Special Hospital | 283XC2000X | 30-036 | MD | Y | Hospitals | Rehabilitation Hospital | Children |
ID Information
| ID | Type | State | Issuer | Description | 951185700 | 05 | MD | MEDICAID |