Provider Demographics
NPI:1063579522
Name:KERRY, ROY EUGENE (MD)
Entity type:Individual
Prefix:
First Name:ROY
Middle Name:EUGENE
Last Name:KERRY
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 1:17 6TH AVE
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:16125-1237
Mailing Address - Country:US
Mailing Address - Phone:724-588-2600
Mailing Address - Fax:724-588-6427
Practice Address - Street 1:17 6TH AVE
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:PA
Practice Address - Zip Code:16125-1237
Practice Address - Country:US
Practice Address - Phone:724-588-2600
Practice Address - Fax:724-588-6427
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD008220E174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0007258300001Medicaid
OH0162158Medicaid
PAE52728Medicare UPIN
OH0162158Medicaid