Basic Information
Provider Information | |||||||||
NPI: | 1124231824 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KERN | ||||||||
FirstName: | BRIAN | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 510 LINCOLN DRIVE | ||||||||
Address2: | P | ||||||||
City: | HERRIN | ||||||||
State: | IL | ||||||||
PostalCode: | 62948 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6189976800 | ||||||||
FaxNumber: | 6188971187 | ||||||||
Practice Location | |||||||||
Address1: | 4787 ALBEN BARKLEY DR | ||||||||
Address2: | SUITE 103 | ||||||||
City: | PADUCAH | ||||||||
State: | KY | ||||||||
PostalCode: | 420016789 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2704429461 | ||||||||
FaxNumber: | 2704410079 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/08/2007 | ||||||||
LastUpdateDate: | 08/14/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 42872 | KY | Y |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |   |
ID Information
ID | Type | State | Issuer | Description | 000000639572 | 01 | KY | ANTHEM | OTHER | 7100091680 | 05 | KY |   | MEDICAID |