Provider Demographics
NPI:1396757571
Name:REDCROSS, KENNETH EDWARD (MD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:EDWARD
Last Name:REDCROSS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:189 STORER AVE
Mailing Address - Street 2:
Mailing Address - City:NEW ROCHELLE
Mailing Address - State:NY
Mailing Address - Zip Code:10801-3133
Mailing Address - Country:US
Mailing Address - Phone:818-633-1556
Mailing Address - Fax:
Practice Address - Street 1:475 WHITE PLAINS RD STE 14
Practice Address - Street 2:
Practice Address - City:EASTCHESTER
Practice Address - State:NY
Practice Address - Zip Code:10709-5537
Practice Address - Country:US
Practice Address - Phone:914-337-4445
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2014-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY219349207R00000X
CT050577207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAH44315Medicare UPIN