Basic Information
| Provider Information | |||||||||
| NPI: | 1447263942 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VANANTWERP | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 426 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | BERLIN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 155301229 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8142674603 | ||||||||
| FaxNumber: | 8142676467 | ||||||||
| Practice Location | |||||||||
| Address1: | 426 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | BERLIN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 155301229 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8142674603 | ||||||||
| FaxNumber: | 8142676467 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/14/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 207Q00000X | MD025369E | PA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0009359180012 | 05 | PA | MEDICAID |