Provider Demographics
NPI:1699235333
Name:RADDAWI, KENAN TAYSSIR (MD)
Entity type:Individual
Prefix:
First Name:KENAN
Middle Name:TAYSSIR
Last Name:RADDAWI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:KENAN
Other - Middle Name:
Other - Last Name:ALRADDAWI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1925 WOODWINDS DR DEPT OF
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-4445
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:201 E UNIVERSITY PKWY
Practice Address - Street 2:DEPT OF MEDICINE
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21218-2829
Practice Address - Country:US
Practice Address - Phone:410-554-2284
Practice Address - Fax:410-554-2184
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-20
Last Update Date:2022-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN71699207R00000X, 208M00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program