Healthcare Provider Details

I. General information

NPI: 1447274634
Provider Name (Legal Business Name): JAMES DAVID KIELEK PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9101 FRANKLIN SQUARE DR
BALTIMORE MD
21237-3936
US

IV. Provider business mailing address

1230 LANDOVER RD
BALTIMORE MD
21237-2922
US

V. Phone/Fax

Practice location:
  • Phone: 443-777-2002
  • Fax: 443-777-2034
Mailing address:
  • Phone: 410-574-5943
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC00616
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: