Healthcare Provider Details

I. General information

NPI: 1972618296
Provider Name (Legal Business Name): KENNETH A HIRSCH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/19/2006
Last Update Date: 03/13/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 N COUNTRY RD
PORT JEFFERSON NY
11777-2119
US

IV. Provider business mailing address

107 OLD FIELD RD
SETAUKET NY
11733-1639
US

V. Phone/Fax

Practice location:
  • Phone: 631-476-2808
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number148992
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207PE0005X
TaxonomyUndersea and Hyperbaric Medicine (Emergency Medicine) Physician
License Number148992
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: