MEDICARE: MARY ELLEN KOLODIEJ MOEHLENHOF RDN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133V00000X	Registered Dietitian	37002080A	IN
2	133V00000X	Registered Dietitian	164005409	IL

General Provider Information

NPI Number	:	1871315333
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY ELLEN KOLODIEJ MOEHLENHOF RDN

Provider Business Mailing Address
First Line	:	2717 SHOREWOOD DR
Second Line	:
City	:	LONG BEACH
State	:	IN
Zip	:	46360-2291
Country	:	US
Telephone Number	:	219-871-9037
Fax Number	:

Provider Business Practice Location Address
First Line	:	2717 SHOREWOOD DR
Second Line	:
City	:	LONG BEACH
State	:	IN
Zip	:	46360-2291
Country	:	US
Telephone Number	:	219-871-9037
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/28/2024
Last Update Date	:	10/28/2024

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