=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699043133
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MACIEJ CHODYNICKI MD LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/13/2011
-----------------------------------------------------
Last Update Date | 12/13/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1122 KENILWORTH DR STE 403
-----------------------------------------------------
City | TOWSON
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21204-2147
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 443-762-1683
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1122 KENILWORTH DR STE 403
-----------------------------------------------------
City | TOWSON
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21204-2147
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MACIEJ CHODYNICKI
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 443-762-1683
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0802X
-----------------------------------------------------
Taxonomy Name | Addiction Psychiatry Physician
-----------------------------------------------------
License Number | D0063080
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------