Healthcare Provider Details

I. General information

NPI: 1992822217
Provider Name (Legal Business Name): KEVIN SCOTT GRODNITZKY M.S., R.D., L.D.N.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2007
Last Update Date: 11/27/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 DIVISION ST
BALTIMORE MD
21217-3121
US

IV. Provider business mailing address

1 TROTTERS CT APT 102
PIKESVILLE MD
21208-6722
US

V. Phone/Fax

Practice location:
  • Phone: 410-728-4091
  • Fax:
Mailing address:
  • Phone: 917-576-4115
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License NumberDX2677
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDX2677
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: