1134147978 NPI number — BEN W KITTREDGE MD

Table of content: BEN W KITTREDGE MD (NPI 1134147978)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134147978 NPI number — BEN W KITTREDGE MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KITTREDGE
Provider First Name:
BEN
Provider Middle Name:
W
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1134147978
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 75868
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BALTIMORE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21275-5868
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
703-383-6469
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6355 WALKER LANE
Provider Second Line Business Practice Location Address:
SUITE 202
Provider Business Practice Location Address City Name:
ALEXANDRIA
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22310-3257
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
703-810-5210
Provider Business Practice Location Address Fax Number:
703-810-5418
Provider Enumeration Date:
07/18/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X , with the licence number:  0101055642 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207X00000X , with the licence number: D51741 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207XX0005X , with the licence number: D51741 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: M77089 . This is a "CONTROLLED SUBSTANCE LICENSE" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 6408028 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: D51741 . This is a "MARYLAND MEDICAL LICENSE" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".




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