Provider Demographics
NPI:1619980448
Name:FERENTZ, KEVIN SCOTT (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:SCOTT
Last Name:FERENTZ
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:PO BOX 418953
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-8953
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10085 RED RUN BLVD
Practice Address - Street 2:SUITE 306
Practice Address - City:OWINGS MILLS
Practice Address - State:MD
Practice Address - Zip Code:21117-4836
Practice Address - Country:US
Practice Address - Phone:410-581-7804
Practice Address - Fax:410-356-6507
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2015-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD31468207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDB67238Medicare UPIN