Healthcare Provider Details

I. General information

NPI: 1639745458
Provider Name (Legal Business Name): BENNETT KOBITZ CSA, CST
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/02/2021
Last Update Date: 06/02/2021
Certification Date: 06/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 TWIN SPRINGS RD
HALETHORPE MD
21227-3553
US

IV. Provider business mailing address

7656 OLD ROCKBRIDGE DR
ELKRIDGE MD
21075-6166
US

V. Phone/Fax

Practice location:
  • Phone: 410-737-5720
  • Fax:
Mailing address:
  • Phone: 831-359-1859
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code246ZS0410X
TaxonomySurgical Technologist
License NumberST.0005969
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License NumberSA.0002781
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: