Healthcare Provider Details

I. General information

NPI: 1619977543
Provider Name (Legal Business Name): GUY KEDZIORA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2005
Last Update Date: 01/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1915 LAKE AVE
PLYMOUTH IN
46563-9366
US

IV. Provider business mailing address

100 E WAYNE ST STE 510
SOUTH BEND IN
46601-2349
US

V. Phone/Fax

Practice location:
  • Phone: 574-935-2353
  • Fax: 574-935-2373
Mailing address:
  • Phone: 574-334-5390
  • Fax: 574-334-5368

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number01039718
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: