Healthcare Provider Details

I. General information

NPI: 1417517608
Provider Name (Legal Business Name): ANDREW KILGORE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2019
Last Update Date: 04/23/2024
Certification Date: 04/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 N WOLFE ST
BALTIMORE MD
21264-4502
US

IV. Provider business mailing address

6201 GREENLEIGH AVE
BALTIMORE MD
21220-2004
US

V. Phone/Fax

Practice location:
  • Phone: 410-955-5080
  • Fax:
Mailing address:
  • Phone: 410-933-6340
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberD0100003
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number4351045719
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: