Provider Demographics
NPI:1619075926
Name:KENNEDY KRIEGER CHILDREN'S HOSPITAL, INC.
Entity Type:Organization
Organization Name:KENNEDY KRIEGER CHILDREN'S HOSPITAL, INC.
Other - Org Name:KENNEDY KRIEGER INSTITUTE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:AVP, APPLICATION SUPPORT
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:BADIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:443-923-1812
Mailing Address - Street 1:PO BOX 45944
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21297-5944
Mailing Address - Country:US
Mailing Address - Phone:443-923-1886
Mailing Address - Fax:443-923-1875
Practice Address - Street 1:707 N BROADWAY
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21205-1832
Practice Address - Country:US
Practice Address - Phone:443-923-1870
Practice Address - Fax:443-923-9405
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2024-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD30036261QD1600X
281PC2000X, 283Q00000X, 283X00000X, 283XC2000X
MD30-036282E00000X, 284300000X
MD802291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities
No281PC2000XHospitalsChronic Disease HospitalChildren
No282E00000XHospitalsLong Term Care Hospital
No283Q00000XHospitalsPsychiatric Hospital
No283X00000XHospitalsRehabilitation Hospital
No283XC2000XHospitalsRehabilitation HospitalChildren
No284300000XHospitalsSpecial Hospital
No291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD955675300Medicaid
MDMD9OtherBLUE CROSS FEDERAL
MD59351301OtherBLUE CROSS OF MARYLAND
MD955675300Medicaid