Basic Information
| Provider Information | |||||||||
| NPI: | 1497733752 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GERWECK | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 163 GORE ST | ||||||||
| Address2: | |||||||||
| City: | EAST CAMBRIDGE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021411119 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6176653000 | ||||||||
| FaxNumber: | 6176653099 | ||||||||
| Practice Location | |||||||||
| Address1: | 163 GORE ST | ||||||||
| Address2: | |||||||||
| City: | EAST CAMBRIDGE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021411119 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6176653000 | ||||||||
| FaxNumber: | 6176653099 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/06/2006 | ||||||||
| LastUpdateDate: | 07/19/2013 | ||||||||
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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 | 213776 | MA | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207RG0300X | 213776 | MA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2063221 | 05 | MA | MEDICAID |