Basic Information
| Provider Information | |||||||||
| NPI: | 1114313376 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PEARSON | ||||||||
| FirstName: | E. KERRY | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 745 HASKINS RD STE B | ||||||||
| Address2: | |||||||||
| City: | BOWLING GREEN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 434021600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4193737607 | ||||||||
| FaxNumber: | 4193537076 | ||||||||
| Practice Location | |||||||||
| Address1: | 1039 HASKINS RD UNIT A | ||||||||
| Address2: | |||||||||
| City: | BOWLING GREEN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 434029066 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4193521121 | ||||||||
| FaxNumber: | 4193521179 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/14/2015 | ||||||||
| LastUpdateDate: | 06/15/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 34.013596 | OH | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0141935 | 05 | OH | MEDICAID |