MEDICARE: KINGDOM MEDICINE ADMINISTRATIVE SERVICES, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician
2	207R00000X	Internal Medicine Physician

General Provider Information

NPI Number	:	1164984977
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KINGDOM MEDICINE ADMINISTRATIVE SERVICES, INC.

Provider Business Mailing Address
First Line	:	8401 SUMMIT AVE
Second Line	:
City	:	WINDSOR MILL
State	:	MD
Zip	:	21244-1169
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	90 PAINTERS MILL RD STE 205
Second Line	:
City	:	OWINGS MILLS
State	:	MD
Zip	:	21117-3614
Country	:	US
Telephone Number	:	410-907-1565
Fax Number	:	443-445-4111

Authorized Official
Title or Position	:	PRESIDENT
Name	:	LEONARD ALLISON RICHARDSON
Credential	:	MD
Telephone Number	:	410-381-8078

Provider Enumeration Date	:	04/01/2019
Last Update Date	:	07/07/2024

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