Basic Information
| Provider Information | |||||||||
| NPI: | 1588666143 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KETCHER | ||||||||
| FirstName: | BRENDA | ||||||||
| MiddleName: | G. | ||||||||
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| Credential: | M.D.,P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 124 SAWTOOTH OAK ST | ||||||||
| Address2: | |||||||||
| City: | HOT SPRINGS | ||||||||
| State: | AR | ||||||||
| PostalCode: | 719017160 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5016237800 | ||||||||
| FaxNumber: | 5016237866 | ||||||||
| Practice Location | |||||||||
| Address1: | 124 SAWTOOTH OAK ST | ||||||||
| Address2: | |||||||||
| City: | HOT SPRINGS | ||||||||
| State: | AR | ||||||||
| PostalCode: | 719017160 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5016237800 | ||||||||
| FaxNumber: | 5016237866 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/12/2005 | ||||||||
| LastUpdateDate: | 07/02/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | C8125 | AR | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 126541001 | 05 | AR | MEDICAID | 5J570 | 01 | AR | BCBS | OTHER |