Provider Demographics
NPI:1215327259
Name:KENNEDY KRIEGER ASSOCIATES, INC - MENTAL HEALTH GROUP PROVIDER
Entity type:Organization
Organization Name:KENNEDY KRIEGER ASSOCIATES, INC - MENTAL HEALTH GROUP PROVIDER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT FINANCE
Authorized Official - Prefix:MR
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:J
Authorized Official - Last Name:NEUMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:443-923-1810
Mailing Address - Street 1:P.O. BOX 744865
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374
Mailing Address - Country:US
Mailing Address - Phone:443-923-1872
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
Practice Address - Country:US
Practice Address - Phone:443-923-9200
Practice Address - Fax:443-923-9405
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KENNEDY KRIEGER INSTITUTE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-01-29
Last Update Date:2020-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-SpecialtyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD168641100Medicaid
MDF158OtherBLUE CROSS FEDERAL
MDK631OtherBLUE CROSS MARYLAND