Provider Demographics
NPI:1578652723
Name:MCDONALD, KIMLA RAYE
Entity type:Individual
Prefix:
First Name:KIMLA
Middle Name:RAYE
Last Name:MCDONALD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 64935
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21264-4935
Mailing Address - Country:US
Mailing Address - Phone:443-481-6569
Mailing Address - Fax:443-481-6515
Practice Address - Street 1:2003 MEDICAL PKWY
Practice Address - Street 2:SUITE G50
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401-7992
Practice Address - Country:US
Practice Address - Phone:410-573-1094
Practice Address - Fax:410-573-1097
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2011-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR161100367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
88913701OtherBCBS
0009OtherBCBS
315314OtherAMERIGROUP
1396990OtherAETNA
MD410036100Medicaid
612176400OtherFEDERAL WORKMANS COMP
88913701OtherBCBS