Provider Demographics
NPI:1568426591
Name:STEPHENS, MARK KERRY (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:KERRY
Last Name:STEPHENS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:314 GOFF MOUNTAIN RD
Mailing Address - Street 2:STE 3
Mailing Address - City:CROSS LANES
Mailing Address - State:WV
Mailing Address - Zip Code:25313-6600
Mailing Address - Country:US
Mailing Address - Phone:304-388-7782
Mailing Address - Fax:304-388-7788
Practice Address - Street 1:130 GOFF MOUNTAIN RD
Practice Address - Street 2:
Practice Address - City:CROSS LANES
Practice Address - State:WV
Practice Address - Zip Code:25313-1419
Practice Address - Country:US
Practice Address - Phone:304-388-7070
Practice Address - Fax:304-388-7075
Is Sole Proprietor?:No
Enumeration Date:2006-04-14
Last Update Date:2017-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV14020207R00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
930063432OtherRAILROAD MEDICARE
WV0070668000Medicaid
A72427Medicare UPIN
WV0070668000Medicaid
930063432Medicare PIN
ST0848235Medicare PIN
ST0848233Medicare PIN
930063432OtherRAILROAD MEDICARE