Provider Demographics
NPI:1306864202
Name:IRVIS, KENNETH M (MD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:M
Last Name:IRVIS
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 1:860 S WHITE HORSE PIKE
Mailing Address - Street 2:
Mailing Address - City:HAMMONTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08037-2018
Mailing Address - Country:US
Mailing Address - Phone:609-567-0200
Mailing Address - Fax:609-567-1169
Practice Address - Street 1:860 S WHITE HORSE PIKE
Practice Address - Street 2:
Practice Address - City:HAMMONTON
Practice Address - State:NJ
Practice Address - Zip Code:08037-2018
Practice Address - Country:US
Practice Address - Phone:609-567-0200
Practice Address - Fax:609-567-1169
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2007-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA08082600207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0110779Medicaid
NJ103585Medicare PIN
B33625Medicare UPIN