Provider Demographics
NPI:1528181880
Name:KA MEDICAL CENTER
Entity Type:Organization
Organization Name:KA MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:HENRY
Authorized Official - Middle Name:GRACE
Authorized Official - Last Name:KAKEMBO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:419-675-3394
Mailing Address - Street 1:448 N LUZERNE AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21224-1116
Mailing Address - Country:US
Mailing Address - Phone:410-675-3394
Mailing Address - Fax:410-675-8056
Practice Address - Street 1:448 N LUZERNE AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21224-1116
Practice Address - Country:US
Practice Address - Phone:410-675-3394
Practice Address - Fax:410-675-8056
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0042217207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty