Provider Demographics
NPI:1174590244
Name:KIENZLE, G. EDWARD (MD)
Entity type:Individual
Prefix:
First Name:G. EDWARD
Middle Name:
Last Name:KIENZLE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 INDUSTRIAL BLVD
Mailing Address - Street 2:SUITE 204
Mailing Address - City:PAOLI
Mailing Address - State:PA
Mailing Address - Zip Code:19301-1607
Mailing Address - Country:US
Mailing Address - Phone:610-647-1484
Mailing Address - Fax:610-647-7068
Practice Address - Street 1:17 INDUSTRIAL BLVD
Practice Address - Street 2:SUITE 204
Practice Address - City:PAOLI
Practice Address - State:PA
Practice Address - Zip Code:19301-1607
Practice Address - Country:US
Practice Address - Phone:610-647-1484
Practice Address - Fax:610-647-7068
Is Sole Proprietor?:No
Enumeration Date:2006-03-07
Last Update Date:2007-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD007413E208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
E57346Medicare UPIN
PA018021Medicare ID - Type Unspecified