=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407067374
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KENNETH H. FISCHBECK M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/24/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 35-2A1000 35 CONVENT DR MSC 3705
-----------------------------------------------------
City | BETHESDA
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20892-0001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-435-9318
-----------------------------------------------------
Fax | 301-480-3365
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 35-2A1000, 35 CONVENT DR. MSC 3705
-----------------------------------------------------
City | BETHESDA
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20892-3705
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-435-9318
-----------------------------------------------------
Fax | 301-480-3365
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084N0400X
-----------------------------------------------------
Taxonomy Name | Neurology Physician
-----------------------------------------------------
License Number | MD025526E
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------