=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093817363
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ROBERT MARK KERRY MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/05/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3421 MEDICAL PARK DR ST FRANCIS NORTH HOSPITAL
-----------------------------------------------------
City | MONROE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71211
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-388-7874
-----------------------------------------------------
Fax | 318-361-4629
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 548 MORGAN HARE RD
-----------------------------------------------------
City | MONROE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71203-8414
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-345-3867
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207P00000X
-----------------------------------------------------
Taxonomy Name | Emergency Medicine Physician
-----------------------------------------------------
License Number | 017151
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------