Healthcare Provider Details

I. General information

NPI: 1699235333
Provider Name (Legal Business Name): KENAN TAYSSIR RADDAWI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: KENAN ALRADDAWI MD

II. Dates (important events)

Enumeration Date: 03/20/2019
Last Update Date: 10/18/2022
Certification Date: 06/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 E UNIVERSITY PKWY DEPT OF MEDICINE
BALTIMORE MD
21218-2829
US

IV. Provider business mailing address

1925 WOODWINDS DR DEPT OF
WOODBURY MN
55125-4445
US

V. Phone/Fax

Practice location:
  • Phone: 410-554-2284
  • Fax: 410-554-2184
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number71699
License Number StateMN
# 3
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number71699
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: