Basic Information
Provider Information | |||||||||
NPI: | 1871556589 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MAHAN | ||||||||
FirstName: | KERRY | ||||||||
MiddleName: | ELIZABETH | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 21850 | ||||||||
Address2: |   | ||||||||
City: | HOT SPRINGS | ||||||||
State: | AR | ||||||||
PostalCode: | 719031850 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5016092222 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1 MERCY LN | ||||||||
Address2: | SUITE 201 | ||||||||
City: | HOT SPRINGS | ||||||||
State: | AR | ||||||||
PostalCode: | 719136442 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5016092222 | ||||||||
FaxNumber: | 5013219689 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/11/2006 | ||||||||
LastUpdateDate: | 11/09/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 11/09/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | M0476 | TX | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 208M00000X | E-2055 | AR | Y |   | Allopathic & Osteopathic Physicians | Hospitalist |   |
ID Information
ID | Type | State | Issuer | Description | 170823201 | 05 | TX |   | MEDICAID | 137704001 | 05 | AR |   | MEDICAID | 170823204 | 05 | TX |   | MEDICAID | 170823205 | 05 | TX |   | MEDICAID | 170823206 | 05 | TX |   | MEDICAID | 170823203 | 05 | TX |   | MEDICAID |