Provider Demographics
NPI:1376819920
Name:PERRY, KENNETH JOHN (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:JOHN
Last Name:PERRY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9330 MEDICAL PLAZA DR
Mailing Address - Street 2:
Mailing Address - City:NORTH CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29406-9104
Mailing Address - Country:US
Mailing Address - Phone:843-797-7000
Mailing Address - Fax:
Practice Address - Street 1:525 E 68TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10065-4870
Practice Address - Country:US
Practice Address - Phone:212-746-5026
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-28
Last Update Date:2017-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC39219207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2199757Medicaid