Healthcare Provider Details

I. General information

NPI: 1588626279
Provider Name (Legal Business Name): KENNETH MICHAEL BERRY PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2006
Last Update Date: 02/06/2020
Certification Date: 02/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11110 MEDICAL CAMPUS RD STE 205
HAGERSTOWN MD
21742-6797
US

IV. Provider business mailing address

11110 MEDICAL CAMPUS RD STE 205
HAGERSTOWN MD
21742-6797
US

V. Phone/Fax

Practice location:
  • Phone: 301-665-4950
  • Fax: 301-665-4956
Mailing address:
  • Phone: 301-302-0503
  • Fax: 240-500-1905

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC0002455
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberC0002455
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: