Basic Information
| Provider Information | |||||||||
| NPI: | 1326155417 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GERWIN | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | STUART | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4 KISSEL LN | ||||||||
| Address2: | |||||||||
| City: | MORRISTOWN | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 079603613 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9732676891 | ||||||||
| FaxNumber: | 9736055990 | ||||||||
| Practice Location | |||||||||
| Address1: | 718 SMYTH RD | ||||||||
| Address2: | |||||||||
| City: | MANCHESTER | ||||||||
| State: | NH | ||||||||
| PostalCode: | 031047004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6036244366 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/24/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 24091 | NJ | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 24091 | 01 | NJ | MEDICAL LICENSE | OTHER |