Basic Information
| Provider Information | |||||||||
| NPI: | 1306872940 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KEPHART | ||||||||
| FirstName: | WILLIS | ||||||||
| MiddleName: | H. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KEPHART | ||||||||
| OtherFirstName: | BILL | ||||||||
| OtherMiddleName: | |||||||||
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| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 6100 PAN AMERICAN EAST FWY NE | ||||||||
| Address2: | STE 100 | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871093427 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5057274500 | ||||||||
| FaxNumber: | 5057274505 | ||||||||
| Practice Location | |||||||||
| Address1: | 4705 MONTGOMERY BLVD NE | ||||||||
| Address2: | STE 301 | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871091226 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5057274500 | ||||||||
| FaxNumber: | 5057274505 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2006 | ||||||||
| LastUpdateDate: | 08/10/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VG0400X | 2000165660 | MO | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecology | 207V00000X | 81-243 | NM | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 100327540B | 05 | KS | MEDICAID | 595985805 | 05 | MO | MEDICAID | 540568508 | 05 | MO | MEDICAID | 32771 | 05 | NM | MEDICAID | 599225901 | 05 | MO | MEDICAID | 100188410A | 05 | OK | MEDICAID | 90036022 | 05 | KS | MEDICAID | 205083603 | 05 | MO | MEDICAID | 595956103 | 05 | MO | MEDICAID | 595956202 | 05 | MO | MEDICAID | 010568509 | 05 | MO | MEDICAID | 595956400 | 05 | MO | MEDICAID |