Healthcare Provider Details
I. General information
NPI: 1699849166
Provider Name (Legal Business Name): KENNETH PATRICK FOWLER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N
II. Dates (important events)
Enumeration Date: 11/17/2006
Last Update Date: 11/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:
III. Provider practice location address
500 MERRIMACK ST
LAWRENCE MA
01843-1756
US
IV. Provider business mailing address
500 MERRIMACK ST
LAWRENCE MA
01843-1756
US
V. Phone/Fax
- Phone: 978-557-8900
- Fax: 978-557-8811
- Phone: 978-557-8900
- Fax: 978-557-8811
VI. Provider taxonomy
Scope of Practice (Provider specialty)
| # 1 | |
| Primary Taxonomy | Y |
| Taxonomy Code | 208000000X |
| Taxonomy | Pediatrics Physician |
| License Number | 232594 |
| License Number State | MA |
| # 2 | |
| Primary Taxonomy | N |
| Taxonomy Code | 207R00000X |
| Taxonomy | Internal Medicine Physician |
| License Number | 232594 |
| License Number State | MA |
VII. Legacy identifiers
For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:
| # 1 | |
| Identifier | 1699849166 |
| Identifier Type | OTHER |
| Identifier State | MA |
| Identifier Issuer | HMO BLUE |
| # 2 | |
| Identifier | 2144409 |
| Identifier Type | MEDICAID |
| Identifier State | MA |
| Identifier Issuer | |
| # 3 | |
| Identifier | 9931092 |
| Identifier Type | OTHER |
| Identifier State | MA |
| Identifier Issuer | AETNA NON HMO |
| # 4 | |
| Identifier | 1699849166 |
| Identifier Type | OTHER |
| Identifier State | MA |
| Identifier Issuer | FALLON COMMUNITY HEALTH PLAN |
| # 5 | |
| Identifier | 946322-02 |
| Identifier Type | OTHER |
| Identifier State | MA |
| Identifier Issuer | NETWORK |
| # 6 | |
| Identifier | 1699849166 |
| Identifier Type | OTHER |
| Identifier State | MA |
| Identifier Issuer | ANTHEM BS |
| # 7 | |
| Identifier | 28-38773 |
| Identifier Type | OTHER |
| Identifier State | MA |
| Identifier Issuer | EVERCARE |
| # 8 | |
| Identifier | 497022 |
| Identifier Type | OTHER |
| Identifier State | MA |
| Identifier Issuer | TUFTS |
| # 9 | |
| Identifier | AA100849 |
| Identifier Type | OTHER |
| Identifier State | MA |
| Identifier Issuer | HARVARD PILGRIM HEALTH CARE |
| # 10 | |
| Identifier | J42491 |
| Identifier Type | OTHER |
| Identifier State | MA |
| Identifier Issuer | BCBS |
| # 11 | |
| Identifier | 110077563A |
| Identifier Type | MEDICAID |
| Identifier State | MA |
| Identifier Issuer | |
| # 12 | |
| Identifier | 30209506 |
| Identifier Type | OTHER |
| Identifier State | NH |
| Identifier Issuer | NH MEDICAID |
| # 13 | |
| Identifier | 9013557 |
| Identifier Type | OTHER |
| Identifier State | MA |
| Identifier Issuer | CIGNA |
| # 14 | |
| Identifier | 0043950 |
| Identifier Type | OTHER |
| Identifier State | MA |
| Identifier Issuer | NEIGHBORHOOD HEALTH PLAN |
| # 15 | |
| Identifier | 1699849166 |
| Identifier Type | OTHER |
| Identifier State | MA |
| Identifier Issuer | AETNA HMO |
VIII. Authorized Official
Name:
Title or Position:
Credential:
Phone:
