1336140748 NPI number — DR. DANIEL JAY KONICK M.D.

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336140748 NPI number — DR. DANIEL JAY KONICK M.D.

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:

KONICK

Provider First Name:

DANIEL

Provider Middle Name:

JAY

Provider Name Prefix Text:

DR.

Provider Name Suffix Text:

Provider Credential Text:

M.D.

Provider Gender Code:

M

Provider Other Organization Name:

Provider Other Organization Name Type Code:

Provider Other Last Name:

Provider Other First Name:

Provider Other Middle Name:

Provider Other Name Prefix Text:

Provider Other Name Suffix Text:

Provider Other Credential Text:

Provider Other Last Name Type Code:

NPI Number:

1336140748

Entity Type Code:

Individual

Replacement NPI:

Last Update Date:

05/24/2012

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

1111 BENFIELD BLVD

Provider Second Line Business Mailing Address:

SUITE 200

Provider Business Mailing Address City Name:

MILLERSVILLE

Provider Business Mailing Address State Name:

MD

Provider Business Mailing Address Postal Code:

21108-3002

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

410-729-5100

Provider Business Mailing Address Fax Number:

410-729-5156

Provider First Line Business Practice Location Address:

125 SHOREWAY DR

Provider Second Line Business Practice Location Address:

SUITE 120

Provider Business Practice Location Address City Name:

QUEENSTOWN

Provider Business Practice Location Address State Name:

MD

Provider Business Practice Location Address Postal Code:

21658-1666

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

410-827-4001

Provider Business Practice Location Address Fax Number:

410-827-4333

Provider Enumeration Date:

08/09/2005

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

• Taxonomy code: 207R00000X , with the licence number:  D0032353 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: 248738 . This is a "MAMSI SPECIALIST" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
• Identifier: 159031600 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
• Identifier: 529991-06 . This is a "CAREFIRST MD RENDERING" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
• Identifier: 7605-0043 . This is a "CAREFIRST BLUECHOICE" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
• Identifier: 848738 . This is a "MAMSI PRIMARY CARE" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
• Identifier: 3086076 . This is a "CIGNA PIN" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
• Identifier: 5360473 . This is a "AETNA FEE FOR SERVICE" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
• Identifier: 0927385 . This is a "AETNA CAPITATED" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
• Identifier: 032388 . This is a "JHHC PROVIDER NUMBER" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
• Identifier: P12855 . This is a "CAREFIRST MPOS" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
• Identifier: 110183169 . This is a "RR MEDICARE" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".