Provider Demographics
NPI:1649260753
Name:PRENDERGAST, KATHLEEN (MD)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:PRENDERGAST
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:GLEN BURNIE
Mailing Address - State:MD
Mailing Address - Zip Code:21061-5803
Mailing Address - Country:US
Mailing Address - Phone:410-787-4594
Mailing Address - Fax:410-787-4846
Practice Address - Street 1:300 HOSPITAL DR
Practice Address - Street 2:SUITE 119
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21061-6902
Practice Address - Country:US
Practice Address - Phone:410-787-4940
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-28
Last Update Date:2014-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0063787207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD62213902OtherCAREFIRST BLUE CROSS
MD108887OtherJOHNS HOPKINS HEALTH CARE
MD5831489OtherAETNA PPO
MD7973311OtherCIGNA
MD4987OtherBRAVO/ ELDER HEALTH
DCF591-0022OtherCAREFIRST BLUE CROSS
MD403539901Medicaid
MD194995OtherAMERIGROUP
MD3301092OtherUHC/AMERICHOICE
MD1080315OtherAETNA HMO
MDKSO4M296Medicare PIN
MDM296Medicare PIN
MD3301092OtherUHC/AMERICHOICE