Basic Information
Provider Information | |||||||||
NPI: | 1740423912 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SAGER | ||||||||
FirstName: | KRISTEN | ||||||||
MiddleName: | WORTMAN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 117287 | ||||||||
Address2: |   | ||||||||
City: | ATLANTA | ||||||||
State: | GA | ||||||||
PostalCode: | 303687287 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8662660555 | ||||||||
FaxNumber: | 8662664999 | ||||||||
Practice Location | |||||||||
Address1: | 136 HEALTH PARK DR | ||||||||
Address2: |   | ||||||||
City: | MENA | ||||||||
State: | AR | ||||||||
PostalCode: | 719539072 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5016247700 | ||||||||
FaxNumber: | 5016235788 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/16/2009 | ||||||||
LastUpdateDate: | 05/13/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/13/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0003X | MD.207903 | LA | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology | 207RX0202X | E-15238 | AR | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Medical Oncology |
ID Information
ID | Type | State | Issuer | Description | 427354YNVB | 01 | LA | MEDICARE PTAN | OTHER | 2400100 | 05 | LA |   | MEDICAID |