Provider Demographics
NPI:1992020457
Name:SCILLA, KATHERINE A (MD)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:A
Last Name:SCILLA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KATHERINE
Other - Middle Name:A
Other - Last Name:SCHRENK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:22 S GREENE ST
Mailing Address - Street 2:ROOM N9E17
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21201-1544
Mailing Address - Country:US
Mailing Address - Phone:410-328-6841
Mailing Address - Fax:410-328-8668
Practice Address - Street 1:22 S GREENE ST
Practice Address - Street 2:ROOM N9E17
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-1544
Practice Address - Country:US
Practice Address - Phone:410-328-6841
Practice Address - Fax:410-328-8668
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-28
Last Update Date:2015-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MDD75549207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD333924600Medicaid
MDS062-0523OtherCAREFIRST BC/BS
MDS062-0523OtherCAREFIRST BC/BS