Healthcare Provider Details

I. General information

NPI: 1902847049
Provider Name (Legal Business Name): KEVIN DUFFUS MSPT, CSCS, CERT MDT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2006
Last Update Date: 08/02/2024
Certification Date: 08/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

321 DORCHESTER AVE STE B
CAMBRIDGE MD
21613-2425
US

IV. Provider business mailing address

2122 YORK RD STE 300
OAK BROOK IL
60523-1925
US

V. Phone/Fax

Practice location:
  • Phone: 410-228-5100
  • Fax:
Mailing address:
  • Phone: 630-575-1980
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberQA05548
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberCP032776T
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: