Healthcare Provider Details

I. General information

NPI: 1073098778
Provider Name (Legal Business Name): KENNEDI VAN EYKEN ATC/LAT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/27/2018
Last Update Date: 09/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 E COLD SPRING LN
BALTIMORE MD
21251-0001
US

IV. Provider business mailing address

1700 E COLD SPRING LN
BALTIMORE MD
21251-0001
US

V. Phone/Fax

Practice location:
  • Phone: 443-885-3333
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RS0010X
TaxonomySports Medicine (Internal Medicine) Physician
License NumberA0001123
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: