MEDICARE: DR. TIMOTHY ROBERT KANIECKI MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RR0500X	Rheumatology Physician	D0100076	MD

General Provider Information

NPI Number	:	1063070928
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TIMOTHY ROBERT KANIECKI MD

Provider Business Mailing Address
First Line	:	6201 GREENLEIGH AVE
Second Line	:
City	:	MIDDLE RIVER
State	:	MD
Zip	:	21220-2004
Country	:	US
Telephone Number	:	410-933-6423
Fax Number	:	410-500-4266

Provider Business Practice Location Address
First Line	:	MASON F. LORD BUILDING, SUITE 4100
Second Line	:	5200 EASTERN AVENUE
City	:	BALTIMORE
State	:	MD
Zip	:	21224
Country	:	US
Telephone Number	:	410-550-2044
Fax Number	:	410-550-2072

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/04/2019
Last Update Date	:	08/06/2024

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