Basic Information
| Provider Information | |||||||||
| NPI: | 1578652723 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MCDONALD | ||||||||
| FirstName: | KIMLA | ||||||||
| MiddleName: | RAYE | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 64935 | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212644935 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4434816569 | ||||||||
| FaxNumber: | 4434816515 | ||||||||
| Practice Location | |||||||||
| Address1: | 2003 MEDICAL PKWY | ||||||||
| Address2: | SUITE G50 | ||||||||
| City: | ANNAPOLIS | ||||||||
| State: | MD | ||||||||
| PostalCode: | 214017992 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4105731094 | ||||||||
| FaxNumber: | 4105731097 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2006 | ||||||||
| LastUpdateDate: | 12/20/2011 | ||||||||
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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 | 367A00000X | R161100 | MD | Y | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |
ID Information
| ID | Type | State | Issuer | Description | 88913701 | 01 | BCBS | OTHER | 0009 | 01 | BCBS | OTHER | 315314 | 01 | AMERIGROUP | OTHER | 1396990 | 01 | AETNA | OTHER | 410036100 | 05 | MD | MEDICAID | 612176400 | 01 | FEDERAL WORKMANS COMP | OTHER |