Provider Demographics
NPI:1588666143
Name:KETCHER, BRENDA G (MD,PA)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:G
Last Name:KETCHER
Suffix:
Gender:F
Credentials:MD,PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 SAWTOOTH OAK ST
Mailing Address - Street 2:
Mailing Address - City:HOT SPRINGS
Mailing Address - State:AR
Mailing Address - Zip Code:71901-7160
Mailing Address - Country:US
Mailing Address - Phone:501-623-7800
Mailing Address - Fax:501-623-7866
Practice Address - Street 1:124 SAWTOOTH OAK ST
Practice Address - Street 2:
Practice Address - City:HOT SPRINGS
Practice Address - State:AR
Practice Address - Zip Code:71901-7160
Practice Address - Country:US
Practice Address - Phone:501-623-7800
Practice Address - Fax:501-623-7866
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-12
Last Update Date:2014-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC8125207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR126541001Medicaid
AR5J570OtherBCBS
AR126541001Medicaid