Healthcare Provider Details

I. General information

NPI: 1174695670
Provider Name (Legal Business Name): KENNETH M. KLEBANOW, M.D. & ASSOCIATES, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/14/2006
Last Update Date: 07/28/2022
Certification Date: 07/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8821 C0LUMBIA 100 PKWY
COLUMBIA MD
21045
US

IV. Provider business mailing address

8821 C0LUMBIA 100 PARKWAY
COLUMBIA MD
21045
US

V. Phone/Fax

Practice location:
  • Phone: 410-992-0513
  • Fax: 410-740-8315
Mailing address:
  • Phone: 410-992-0513
  • Fax: 410-740-8315

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number
License Number StateMD

VIII. Authorized Official

Name: DR. KENNETH M KLEBANOW
Title or Position: PRESIDENT, MANAGING PARTNER
Credential: M.D.
Phone: 410-992-0515