1295725349 NPI number — KENNETH MICHAEL KUDELKO M.D.

Table of content: KENNETH MICHAEL KUDELKO M.D. (NPI 1295725349)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295725349 NPI number — KENNETH MICHAEL KUDELKO M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KUDELKO
Provider First Name:
KENNETH
Provider Middle Name:
MICHAEL
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1295725349
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/16/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7500 HANOVER PKWY
Provider Second Line Business Mailing Address:
SUITE 201
Provider Business Mailing Address City Name:
GREENBELT
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
20770-2010
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
202-365-3284
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7500 HANOVER PKWY
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
GREENBELT
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
20770-2010
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
301-982-7944
Provider Business Practice Location Address Fax Number:
301-441-8696
Provider Enumeration Date:
10/28/2005

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: 2084N0400X , with the licence number:  D58407 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 002848291001 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 9874006 . This is a "CIGNA" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 912931600 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 16540021 . This is a "CAREFIRST BCBS" identifier , issued by the state of ( DC ) . This identifiers is of the category "OTHER".
  • Identifier: 941847 . This is a "NCPPO" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 9232080 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".




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