Provider Demographics
NPI:1063557924
Name:KERBS, IDA MAE
Entity type:Individual
Prefix:MRS
First Name:IDA
Middle Name:MAE
Last Name:KERBS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2136 MORNINGSIDE DRIVE
Mailing Address - Street 2:
Mailing Address - City:EMPORIA
Mailing Address - State:KS
Mailing Address - Zip Code:66801-5452
Mailing Address - Country:US
Mailing Address - Phone:620-341-9682
Mailing Address - Fax:620-345-1968
Practice Address - Street 1:2136 MORNINGSIDE DR
Practice Address - Street 2:
Practice Address - City:EMPORIA
Practice Address - State:KS
Practice Address - Zip Code:66801-5452
Practice Address - Country:US
Practice Address - Phone:620-341-9682
Practice Address - Fax:620-345-1968
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS0886905701Medicaid