Provider Demographics
NPI:1396706214
Name:ROBERT, KENNETH (MD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:ROBERT
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 1:1385 MEDICAL CENTER DR
Mailing Address - Street 2:
Mailing Address - City:ROANOKE RAPIDS
Mailing Address - State:NC
Mailing Address - Zip Code:27870-5130
Mailing Address - Country:US
Mailing Address - Phone:252-537-9176
Mailing Address - Fax:252-537-6851
Practice Address - Street 1:1385 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:ROANOKE RAPIDS
Practice Address - State:NC
Practice Address - Zip Code:27870-5130
Practice Address - Country:US
Practice Address - Phone:252-537-9176
Practice Address - Fax:252-537-6851
Is Sole Proprietor?:No
Enumeration Date:2006-03-30
Last Update Date:2022-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC117385207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89134RYMedicaid
NC2022460Medicare ID - Type Unspecified
NC89134RYMedicaid