Basic Information
| Provider Information | |||||||||
| NPI: | 1134147978 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KITTREDGE | ||||||||
| FirstName: | BEN | ||||||||
| MiddleName: | W | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 75868 | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212755868 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7033836469 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 6355 WALKER LANE | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | ALEXANDRIA | ||||||||
| State: | VA | ||||||||
| PostalCode: | 223103257 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7038105210 | ||||||||
| FaxNumber: | 7038105418 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2006 | ||||||||
| LastUpdateDate: | 03/02/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 0101055642 | VA | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207X00000X | D51741 | MD | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207XX0005X | D51741 | MD | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine |
ID Information
| ID | Type | State | Issuer | Description | M77089 | 01 | MD | CONTROLLED SUBSTANCE LICENSE | OTHER | 6408028 | 05 | VA | MEDICAID | FK3672436 | 01 | MD | MARYLAND DEA LICENSE | OTHER | D51741 | 01 | MD | MARYLAND MEDICAL LICENSE | OTHER |