Provider Demographics
NPI:1962416651
Name:CERTA, KENNETH M (MD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:M
Last Name:CERTA
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 1:833 CHESTNUT ST
Mailing Address - Street 2:SUITE 210
Mailing Address - City:PHILA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-4414
Mailing Address - Country:US
Mailing Address - Phone:215-955-6655
Mailing Address - Fax:215-923-8219
Practice Address - Street 1:833 CHESTNUT ST
Practice Address - Street 2:SUITE 210
Practice Address - City:PHILA
Practice Address - State:PA
Practice Address - Zip Code:19107-4414
Practice Address - Country:US
Practice Address - Phone:215-955-6655
Practice Address - Fax:215-923-8219
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2008-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD024309E2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0009959520007Medicaid
260038235OtherRR MEDICARE
PACE416500OtherBLUE SHIELD OF PA
PA41650Medicare ID - Type Unspecified
260038235OtherRR MEDICARE
PAB41437Medicare UPIN