Healthcare Provider Details

I. General information

NPI: 1619075926
Provider Name (Legal Business Name): KENNEDY KRIEGER CHILDREN'S HOSPITAL, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 01/19/2024
Certification Date: 01/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

707 N BROADWAY
BALTIMORE MD
21205-1832
US

IV. Provider business mailing address

PO BOX 45944
BALTIMORE MD
21297-5944
US

V. Phone/Fax

Practice location:
  • Phone: 443-923-1870
  • Fax: 443-923-9405
Mailing address:
  • Phone: 443-923-1886
  • Fax: 443-923-1875

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code281PC2000X
TaxonomyChildren's Chronic Disease Hospital
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code282E00000X
TaxonomyLong Term Care Hospital
License Number30-036
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code283Q00000X
TaxonomyPsychiatric Hospital
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code283X00000X
TaxonomyRehabilitation Hospital
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code283XC2000X
TaxonomyChildren's Rehabilitation Hospital
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code284300000X
TaxonomySpecial Hospital
License Number30-036
License Number StateMD
# 7
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number802
License Number StateMD
# 8
Primary TaxonomyY
Taxonomy Code261QD1600X
TaxonomyDevelopmental Disabilities Clinic/Center
License Number30036
License Number StateMD

VIII. Authorized Official

Name: LISA BADIE
Title or Position: AVP, APPLICATION SUPPORT
Credential:
Phone: 443-923-1812