Healthcare Provider Details

I. General information

NPI: 1871537621
Provider Name (Legal Business Name): FREDRICK WAYNE KERSH DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2006
Last Update Date: 12/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3110 PARK CENTER DR
TYLER TX
75701-9215
US

IV. Provider business mailing address

PO BOX 130757
TYLER TX
75713-0757
US

V. Phone/Fax

Practice location:
  • Phone: 903-593-9999
  • Fax: 903-526-4239
Mailing address:
  • Phone: 903-593-9999
  • Fax: 903-526-4239

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberH4460
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberH4460
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code2083P0500X
TaxonomyPreventive Medicine/Occupational Environmental Medicine Physician
License NumberH4460
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: