Basic Information
| Provider Information | |||||||||
| NPI: | 1477515344 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SCHWARTZ | ||||||||
| FirstName: | KENNY ALAN | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 N ACADEMY AVE | ||||||||
| Address2: | |||||||||
| City: | DANVILLE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 178224903 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5702149907 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1000 EAST MOUNTAIN BLVD. | ||||||||
| Address2: | |||||||||
| City: | WILKES-BARRE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 187113731 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5708086026 | ||||||||
| FaxNumber: | 5708083208 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/05/2006 | ||||||||
| LastUpdateDate: | 08/10/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | 148738-1 | NY | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084N0400X | MD443317 | PA | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 00838151 | 05 | NY | MEDICAID |