Healthcare Provider Details

I. General information

NPI: 1568426591
Provider Name (Legal Business Name): MARK KERRY STEPHENS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2006
Last Update Date: 10/26/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 GOFF MOUNTAIN RD
CROSS LANES WV
25313-1419
US

IV. Provider business mailing address

314 GOFF MOUNTAIN RD STE 3
CROSS LANES WV
25313-6600
US

V. Phone/Fax

Practice location:
  • Phone: 304-388-7070
  • Fax: 304-388-7075
Mailing address:
  • Phone: 304-388-7782
  • Fax: 304-388-7788

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number14020
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number14020
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: