Provider Demographics
NPI:1497733752
Name:GERWECK, KENNETH K (MD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:K
Last Name:GERWECK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:163 GORE ST
Mailing Address - Street 2:
Mailing Address - City:EAST CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02141-1119
Mailing Address - Country:US
Mailing Address - Phone:617-665-3000
Mailing Address - Fax:617-665-3099
Practice Address - Street 1:163 GORE ST
Practice Address - Street 2:
Practice Address - City:EAST CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02141-1119
Practice Address - Country:US
Practice Address - Phone:617-665-3000
Practice Address - Fax:617-665-3099
Is Sole Proprietor?:No
Enumeration Date:2006-01-06
Last Update Date:2013-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA213776207Q00000X, 207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2063221Medicaid
MAH98750Medicare UPIN
MA2063221Medicaid