Provider Demographics
NPI:1649311754
Name:HARRISON, KENNETH (MD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:
Last Name:HARRISON
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 1:2101 E JEFFERSON ST
Mailing Address - Street 2:KAISER PERMANENTE MEDICARE ENROLLMENT
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20852-4908
Mailing Address - Country:US
Mailing Address - Phone:301-816-2424
Mailing Address - Fax:
Practice Address - Street 1:201 N WASHINGTON ST
Practice Address - Street 2:KAISER PERMANENTE FALLS CHURCH MEDICAL CENTER
Practice Address - City:FALLS CHURCH
Practice Address - State:VA
Practice Address - Zip Code:22046-4518
Practice Address - Country:US
Practice Address - Phone:703-237-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-09
Last Update Date:2022-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD550172085R0202X
DCMD199642085R0202X
VA01010576262085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
E75865Medicare UPIN
007298M92Medicare ID - Type Unspecified
K679L096Medicare ID - Type Unspecified
009130K32Medicare ID - Type Unspecified