Basic Information
| Provider Information | |||||||||
| NPI: | 1770744716 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KIESS | ||||||||
| FirstName: | ANA | ||||||||
| MiddleName: | PONCE | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D., PH.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 401 NORTH BROADWAY | ||||||||
| Address2: | SUITE 1440 | ||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 21231 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4432877528 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 401 S BROADWAY | ||||||||
| Address2: | SUITE 1440 | ||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212312431 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4432877528 | ||||||||
| FaxNumber: | 4105021419 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2008 | ||||||||
| LastUpdateDate: | 12/18/2014 | ||||||||
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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 | 2085R0001X | D75730 | MD | Y | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology | 2085R0203X | D0075730 | MD | N | Allopathic & Osteopathic Physicians | Radiology | Therapeutic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 230340 | 01 | MD | GROUP MC PTAN | OTHER | 069086400 | 05 | MD | MEDICAID |