Basic Information
| Provider Information | |||||||||
| NPI: | 1316950942 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BERRY | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | M | ||||||||
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| Mailing Information | |||||||||
| Address1: | 407 AIRPORT EXECUTIVE PARK | ||||||||
| Address2: | |||||||||
| City: | NANUET | ||||||||
| State: | NY | ||||||||
| PostalCode: | 109545288 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 9002 QUEENS BLVD | ||||||||
| Address2: | |||||||||
| City: | ELMHURST | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113734941 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7185581000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/14/2006 | ||||||||
| LastUpdateDate: | 11/15/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 168383 | NY | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207Q00000X | 168383 | NY | N | Allopathic & Osteopathic Physicians | Family Medicine | 207P00000X | MD039776L | PA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 11890666 | 01 | PA | CAQH | OTHER |