Provider Demographics
NPI: | 1144204819 |
---|---|
Name: | MAHON, KERRIANN (MD) |
Entity Type: | Individual |
Prefix: | |
First Name: | KERRIANN |
Middle Name: | |
Last Name: | MAHON |
Suffix: | |
Gender: | F |
Credentials: | MD |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 101 WILLMAR AVE SW |
Mailing Address - Street 2: | AFFILIATED COMMUNITY MEDICAL CENTERS |
Mailing Address - City: | WILLMAR |
Mailing Address - State: | MN |
Mailing Address - Zip Code: | 56201 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 320-231-5000 |
Mailing Address - Fax: | 320-231-5067 |
Practice Address - Street 1: | 101 WILLMAR AVE SW |
Practice Address - Street 2: | AFFILIATED COMMUNITY MEDICAL CENTERS |
Practice Address - City: | WILLMAR |
Practice Address - State: | MN |
Practice Address - Zip Code: | 56201 |
Practice Address - Country: | US |
Practice Address - Phone: | 320-231-5000 |
Practice Address - Fax: | 320-231-5067 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2005-12-06 |
Last Update Date: | 2022-10-14 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
MN | 47040 | 208M00000X, 208000000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 208000000X | Allopathic & Osteopathic Physicians | Pediatrics | |
No | 208M00000X | Allopathic & Osteopathic Physicians | Hospitalist |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
MN | I09602 | Medicare UPIN | |
MN | 370002875 | Medicare ID - Type Unspecified |