Healthcare Provider Details

I. General information

NPI: 1982125779
Provider Name (Legal Business Name): KMH MEDICAL SERVICE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/30/2017
Last Update Date: 05/27/2025
Certification Date: 05/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5401 BELAIR RD BSMT
BALTIMORE MD
21206-4266
US

IV. Provider business mailing address

5401 BELAIR RD BSMT
BALTIMORE MD
21206-4266
US

V. Phone/Fax

Practice location:
  • Phone: 667-303-3700
  • Fax:
Mailing address:
  • Phone: 667-303-3700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: KELLY MARIE HEYWARD
Title or Position: CRNP
Credential:
Phone: 717-434-8264