Provider Demographics
NPI:1215924402
Name:TELLERMAN, KENNETH (MD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:TELLERMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2416 KEN OAK RD
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21209-4310
Mailing Address - Country:US
Mailing Address - Phone:410-664-6632
Mailing Address - Fax:410-243-0470
Practice Address - Street 1:711 W 40TH ST STE 438
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21211-2199
Practice Address - Country:US
Practice Address - Phone:410-243-8632
Practice Address - Fax:410-243-0470
Is Sole Proprietor?:No
Enumeration Date:2005-10-03
Last Update Date:2021-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0025147208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD350701700Medicaid