=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336140748
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DANIEL JAY KONICK M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/09/2005
-----------------------------------------------------
Last Update Date | 05/24/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 125 SHOREWAY DR SUITE 120
-----------------------------------------------------
City | QUEENSTOWN
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21658-1666
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-827-4001
-----------------------------------------------------
Fax | 410-827-4333
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1111 BENFIELD BLVD SUITE 200
-----------------------------------------------------
City | MILLERSVILLE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21108-3002
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-729-5100
-----------------------------------------------------
Fax | 410-729-5156
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | D0032353
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------