Provider Demographics
NPI:1639170905
Name:PURTILL, KERRY A (MD)
Entity Type:Individual
Prefix:
First Name:KERRY
Middle Name:A
Last Name:PURTILL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 ELM ST
Mailing Address - Street 2:
Mailing Address - City:TUCKAHOE
Mailing Address - State:NY
Mailing Address - Zip Code:10707-3925
Mailing Address - Country:US
Mailing Address - Phone:914-337-7474
Mailing Address - Fax:914-961-0058
Practice Address - Street 1:1 ELM ST
Practice Address - Street 2:
Practice Address - City:TUCKAHOE
Practice Address - State:NY
Practice Address - Zip Code:10707-3925
Practice Address - Country:US
Practice Address - Phone:914-337-7474
Practice Address - Fax:914-961-0058
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2008-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY224666208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02300796Medicaid
NY7R9901Medicare ID - Type Unspecified
NY02300796Medicaid