Healthcare Provider Details

I. General information

NPI: 1316960073
Provider Name (Legal Business Name): KENNETH IRA SANN DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/25/2006
Last Update Date: 05/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

38 ASHLAND ST
NORTH ADAMS MA
01247-4508
US

IV. Provider business mailing address

38 ASHLAND ST
NORTH ADAMS MA
01247-4508
US

V. Phone/Fax

Practice location:
  • Phone: 413-663-5547
  • Fax: 413-664-1057
Mailing address:
  • Phone: 413-663-5547
  • Fax: 413-664-1057

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number1428
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: