Provider Demographics
NPI:1588626279
Name:BERRY, KENNETH MICHAEL (PA-C)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:MICHAEL
Last Name:BERRY
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11110 MEDICAL CAMPUS RD STE 205
Mailing Address - Street 2:
Mailing Address - City:HAGERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21742-6797
Mailing Address - Country:US
Mailing Address - Phone:301-302-0503
Mailing Address - Fax:240-500-1905
Practice Address - Street 1:11110 MEDICAL CAMPUS RD STE 205
Practice Address - Street 2:
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21742-6797
Practice Address - Country:US
Practice Address - Phone:301-665-4950
Practice Address - Fax:301-665-4956
Is Sole Proprietor?:No
Enumeration Date:2006-04-06
Last Update Date:2020-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0002455363AS0400X
C0002455363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDP38006Medicare UPIN