Provider Demographics
NPI:1134308802
Name:KINGDOM MEDICINE PA
Entity type:Organization
Organization Name:KINGDOM MEDICINE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LEONARD
Authorized Official - Middle Name:A
Authorized Official - Last Name:RICHARDSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:410-861-8151
Mailing Address - Street 1:8401 SUMMIT AVE
Mailing Address - Street 2:
Mailing Address - City:WINDSOR MILL
Mailing Address - State:MD
Mailing Address - Zip Code:21244-1169
Mailing Address - Country:US
Mailing Address - Phone:410-381-8078
Mailing Address - Fax:443-445-4111
Practice Address - Street 1:2926 BALTIMORE BLVD STE D
Practice Address - Street 2:
Practice Address - City:FINKSBURG
Practice Address - State:MD
Practice Address - Zip Code:21048-1832
Practice Address - Country:US
Practice Address - Phone:410-861-8151
Practice Address - Fax:443-445-4111
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-30
Last Update Date:2024-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD693604100Medicaid
MD693604100Medicaid
MD444MMedicare PIN