Provider Demographics
NPI:1841285954
Name:STORCH, KENNETH JACK (MD, PHD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:JACK
Last Name:STORCH
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 MALAPARDIS RD STE 202
Mailing Address - Street 2:
Mailing Address - City:CEDAR KNOLLS
Mailing Address - State:NJ
Mailing Address - Zip Code:07927-1121
Mailing Address - Country:US
Mailing Address - Phone:973-240-5000
Mailing Address - Fax:973-765-9366
Practice Address - Street 1:210 MALAPARDIS RD STE 202
Practice Address - Street 2:
Practice Address - City:CEDAR KNOLLS
Practice Address - State:NJ
Practice Address - Zip Code:07927-1121
Practice Address - Country:US
Practice Address - Phone:973-240-5000
Practice Address - Fax:973-765-9366
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-14
Last Update Date:2021-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA05165800207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0246107Medicaid
NJ5026015OtherAETNA
NJ110185640Medicare PIN
NJ5026015OtherAETNA
NJD19312Medicare UPIN