Basic Information
Provider Information | |||||||||
NPI: | 1740272517 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KERNAN | ||||||||
FirstName: | DONALD | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 133 PLEASANT ST | ||||||||
Address2: |   | ||||||||
City: | BERLIN | ||||||||
State: | NH | ||||||||
PostalCode: | 035702006 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6037522040 | ||||||||
FaxNumber: | 6037521709 | ||||||||
Practice Location | |||||||||
Address1: | 2 BROADWAY AVE | ||||||||
Address2: |   | ||||||||
City: | GORHAM | ||||||||
State: | NH | ||||||||
PostalCode: | 035811502 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6034662741 | ||||||||
FaxNumber: | 6034662953 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/18/2005 | ||||||||
LastUpdateDate: | 08/22/2013 | ||||||||
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 | 207Q00000X | 6901 | NH | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   | 207P00000X | 6901 | NH | N |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 0107140YPNH02 | 01 | NH | ANTHEM BC/BS | OTHER | 4147522 | 01 |   | MVP HEALTHCARE | OTHER | 30204170 | 05 | NH |   | MEDICAID | P00186636 | 01 |   | RAILROAD MEDICARE | OTHER | 3072596 | 05 | NH |   | MEDICAID | 6901 | 01 | NH | STATE LICENSE # | OTHER | 2970924001 | 01 | NH | CIGNA HEALTHCARE | OTHER | 5830418 | 01 |   | AETNA GROUP | OTHER | AA28313 | 01 |   | HARVARD PILGRIM | OTHER | AK2693275 | 01 |   | FEDERAL DEA# | OTHER |