Provider Demographics
NPI:1760433536
Name:HERRMANN, KENNETH JAMES (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:JAMES
Last Name:HERRMANN
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 1:2727 MARSHALL COURT
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53705
Mailing Address - Country:US
Mailing Address - Phone:608-238-9354
Mailing Address - Fax:608-238-7675
Practice Address - Street 1:2727 MARSHALL COURT
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53705
Practice Address - Country:US
Practice Address - Phone:608-238-9354
Practice Address - Fax:608-238-7675
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2009-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI341312084P0800X
WI34131-0202084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31921500Medicaid
WI000283040Medicare ID - Type Unspecified
WI31921500Medicaid