Healthcare Provider Details

I. General information

NPI: 1184587412
Provider Name (Legal Business Name): FREDERIC KEDZIOR M.S., RD, LDN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/04/2025
Last Update Date: 12/04/2025
Certification Date: 12/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

265 TOWNSHIP LINE RD
ELKINS PARK PA
19027-2287
US

IV. Provider business mailing address

265 TOWNSHIP LINE RD
ELKINS PARK PA
19027-2287
US

V. Phone/Fax

Practice location:
  • Phone: 215-379-2700
  • Fax:
Mailing address:
  • Phone: 215-379-2700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDN006085
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: