Basic Information
| Provider Information | |||||||||
| NPI: | 1013990720 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STERN | ||||||||
| FirstName: | KATHLEEN | ||||||||
| MiddleName: | W | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 610 SOLAREX CT | ||||||||
| Address2: | |||||||||
| City: | FREDERICK | ||||||||
| State: | MD | ||||||||
| PostalCode: | 217038624 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 610 9TH AVE | ||||||||
| Address2: | |||||||||
| City: | BRUNSWICK | ||||||||
| State: | MD | ||||||||
| PostalCode: | 217161828 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3018347188 | ||||||||
| FaxNumber: | 3018347889 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/28/2005 | ||||||||
| LastUpdateDate: | 08/02/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | D0032073 | MD | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207QG0300X | D0032073 | MD | N | Allopathic & Osteopathic Physicians | Family Medicine | Geriatric Medicine |
ID Information
| ID | Type | State | Issuer | Description | 926580505 | 05 | MD | MEDICAID | 926580501 | 05 | MD | MEDICAID | 926580502 | 05 | MD | MEDICAID |