Healthcare Provider Details

I. General information

NPI: 1497733752
Provider Name (Legal Business Name): KENNETH K GERWECK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/06/2006
Last Update Date: 07/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

163 GORE ST
EAST CAMBRIDGE MA
02141-1119
US

IV. Provider business mailing address

163 GORE ST
EAST CAMBRIDGE MA
02141-1119
US

V. Phone/Fax

Practice location:
  • Phone: 617-665-3000
  • Fax: 617-665-3099
Mailing address:
  • Phone: 617-665-3000
  • Fax: 617-665-3099

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number213776
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number213776
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: