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General NPI Number Information
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NPI Number | 1588626279
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Entity Type | Individual
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Provider Name | KENNETH MICHAEL BERRY PA-C
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Gender | Male
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Dates
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Enumeration Date | 04/06/2006
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Last Update Date | 02/06/2020
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Provider Practice Location Address
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Address Line | 11110 MEDICAL CAMPUS RD STE 205
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City | HAGERSTOWN
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State | MD
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Zip | 21742-6797
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Country | US
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Telephone | 301-665-4950
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Fax | 301-665-4956
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Provider Business Mailing Address
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Address Line | 11110 MEDICAL CAMPUS RD STE 205
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City | HAGERSTOWN
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State | MD
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Zip | 21742-6797
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Country | US
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Telephone | 301-302-0503
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Fax | 240-500-1905
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AS0400X
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Taxonomy Name | Surgical Physician Assistant
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License Number | C0002455
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License Number State | MD
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Taxonomy #2
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | C0002455
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License Number State |
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