Provider Demographics
NPI:1013028091
Name:KRUSE, KENYON W (MD)
Entity Type:Individual
Prefix:
First Name:KENYON
Middle Name:W
Last Name:KRUSE
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:PO BOX 8210
Mailing Address - Street 2:
Mailing Address - City:KALISPELL
Mailing Address - State:MT
Mailing Address - Zip Code:59904-1210
Mailing Address - Country:US
Mailing Address - Phone:701-220-2791
Mailing Address - Fax:
Practice Address - Street 1:310 SUNNYVIEW LN
Practice Address - Street 2:
Practice Address - City:KALISPELL
Practice Address - State:MT
Practice Address - Zip Code:59901-3129
Practice Address - Country:US
Practice Address - Phone:406-752-5111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2018-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND10069207L00000X
MTMED-PHYS-LIC-52109207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND13544Medicaid
NDH71196Medicare UPIN
ND25875Medicare PIN