Basic Information
| Provider Information | |||||||||
| NPI: | 1568426591 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STEPHENS | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | KERRY | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 314 GOFF MOUNTAIN RD | ||||||||
| Address2: | STE 3 | ||||||||
| City: | CROSS LANES | ||||||||
| State: | WV | ||||||||
| PostalCode: | 253136600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043887782 | ||||||||
| FaxNumber: | 3043887788 | ||||||||
| Practice Location | |||||||||
| Address1: | 130 GOFF MOUNTAIN RD | ||||||||
| Address2: | |||||||||
| City: | CROSS LANES | ||||||||
| State: | WV | ||||||||
| PostalCode: | 253131419 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043887070 | ||||||||
| FaxNumber: | 3043887075 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/14/2006 | ||||||||
| LastUpdateDate: | 10/26/2017 | ||||||||
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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 | 207R00000X | 14020 | WV | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207P00000X | 14020 | WV | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 930063432 | 01 | RAILROAD MEDICARE | OTHER | 0070668000 | 05 | WV | MEDICAID |