Basic Information
| Provider Information | |||||||||
| NPI: | 1689090029 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PENCZEK | ||||||||
| FirstName: | GREGORY | ||||||||
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| Credential: | MS, LAT, ATC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8000 YORK RD | ||||||||
| Address2: | FIELD HOUSE 101 | ||||||||
| City: | TOWSON | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212520001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4107042890 | ||||||||
| FaxNumber: | 4107042727 | ||||||||
| Practice Location | |||||||||
| Address1: | 8000 YORK RD | ||||||||
| Address2: | FIELD HOUSE 101 | ||||||||
| City: | TOWSON | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212520001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4107042890 | ||||||||
| FaxNumber: | 4107042727 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/10/2014 | ||||||||
| LastUpdateDate: | 03/10/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2255A2300X | A0000071 | MD | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer |
No ID Information.