Basic Information
| Provider Information | |||||||||
| NPI: | 1205864964 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLANK | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | ROBERT | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 416457 | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 022416457 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8443621735 | ||||||||
| FaxNumber: | 9732907495 | ||||||||
| Practice Location | |||||||||
| Address1: | 97 W PARKWAY | ||||||||
| Address2: | |||||||||
| City: | POMPTON PLAINS | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 074441647 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9738315306 | ||||||||
| FaxNumber: | 9738315305 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2006 | ||||||||
| LastUpdateDate: | 08/09/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0001X | 25MA06871100 | NJ | Y | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
ID Information
| ID | Type | State | Issuer | Description | 7930500 | 05 | NJ | MEDICAID |