Healthcare Provider Details

I. General information

NPI: 1487622007
Provider Name (Legal Business Name): KENNETH ALAN BERLIN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/09/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

876 BROADWAY
RAYNHAM MA
02767-1797
US

IV. Provider business mailing address

876 BROADWAY
RAYNHAM MA
02767-1797
US

V. Phone/Fax

Practice location:
  • Phone: 508-824-9500
  • Fax: 508-824-9507
Mailing address:
  • Phone: 508-824-9500
  • Fax: 508-824-9507

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number52899
License Number StateMA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier6182747
Identifier TypeMEDICAID
Identifier StateMA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: