Basic Information
| Provider Information | |||||||||
| NPI: | 1376819920 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PERRY | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | JOHN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9330 MEDICAL PLAZA DR | ||||||||
| Address2: | |||||||||
| City: | NORTH CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294069104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437977000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 525 E 68TH ST | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100654870 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2127465026 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/28/2012 | ||||||||
| LastUpdateDate: | 01/30/2017 | ||||||||
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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 | 39219 | SC | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2199757 | 05 | LA | MEDICAID |