Basic Information
| Provider Information | |||||||||
| NPI: | 1073690434 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KERNER | ||||||||
| FirstName: | STEPHEN | ||||||||
| MiddleName: | SAMUEL | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 380 9TH ST | ||||||||
| Address2: | |||||||||
| City: | FLORENCE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974399470 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5419977134 | ||||||||
| FaxNumber: | 5419021320 | ||||||||
| Practice Location | |||||||||
| Address1: | 390 9TH ST | ||||||||
| Address2: | |||||||||
| City: | FLORENCE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974399470 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5419977134 | ||||||||
| FaxNumber: | 5419027533 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2006 | ||||||||
| LastUpdateDate: | 12/16/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 34007382 | OH | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 241289 | 05 | OR | MEDICAID | 64103328 | 05 | KY | MEDICAID | 2169513 | 05 | OH | MEDICAID |