Basic Information
| Provider Information | |||||||||
| NPI: | 1669471678 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BENNETT | ||||||||
| FirstName: | KERRY | ||||||||
| MiddleName: | G. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD, MPH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 123 SUMMER ST | ||||||||
| Address2: | SUITE 210 | ||||||||
| City: | WORCESTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 016081216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5083683190 | ||||||||
| FaxNumber: | 5083683193 | ||||||||
| Practice Location | |||||||||
| Address1: | 123 SUMMER ST | ||||||||
| Address2: | SUITE 210 | ||||||||
| City: | WORCESTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 016081216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5083683190 | ||||||||
| FaxNumber: | 5083683193 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2005 | ||||||||
| LastUpdateDate: | 02/18/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 161131 | MA | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 110034723A | 05 | MA | MEDICAID |