Provider Demographics
NPI:1699849166
Name:FOWLER, KENNETH PATRICK (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:PATRICK
Last Name:FOWLER
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 1:500 MERRIMACK ST
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:MA
Mailing Address - Zip Code:01843-1756
Mailing Address - Country:US
Mailing Address - Phone:978-557-8900
Mailing Address - Fax:978-557-8811
Practice Address - Street 1:500 MERRIMACK ST
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:MA
Practice Address - Zip Code:01843-1756
Practice Address - Country:US
Practice Address - Phone:978-557-8900
Practice Address - Fax:978-557-8811
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2012-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA232594208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1699849166OtherHMO BLUE
MA2144409Medicaid
MA9931092OtherAETNA NON HMO
MA1699849166OtherFALLON COMMUNITY HEALTH PLAN
MA946322-02OtherNETWORK
MA1699849166OtherANTHEM BS
MA28-38773OtherEVERCARE
MA497022OtherTUFTS
MAAA100849OtherHARVARD PILGRIM HEALTH CARE
MAJ42491OtherBCBS
MA110077563AMedicaid
NH30209506OtherNH MEDICAID
MA9013557OtherCIGNA
MA0043950OtherNEIGHBORHOOD HEALTH PLAN
MA1699849166OtherAETNA HMO
MA000457101Medicare PIN