MEDICARE: DR. KATHLEEN A. AWALT M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2080A0000X	Pediatric Adolescent Medicine Physician	D47661	MD

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	G20112	OTHER	MD	UPIN
2	M39765	OTHER	MD	CDS

General Provider Information

NPI Number	:	1710954326
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KATHLEEN A. AWALT M.D.

Provider Business Mailing Address
First Line	:	8600 LASALLE RD
Second Line	:	POTOMAC BUILDING SUITE 105
City	:	BALTIMORE
State	:	MD
Zip	:	21286-2001
Country	:	US
Telephone Number	:	410-823-5232
Fax Number	:	410-296-0257

Provider Business Practice Location Address
First Line	:	8600 LASALLE RD
Second Line	:	POTOMAC BUILDING SUITE 105
City	:	BALTIMORE
State	:	MD
Zip	:	21286-2001
Country	:	US
Telephone Number	:	410-823-5232
Fax Number	:	410-296-0257

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/02/2006
Last Update Date	:	03/07/2023

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