Provider Demographics
NPI:1023194800
Name:EBY, KERRY J
Entity Type:Individual
Prefix:
First Name:KERRY
Middle Name:J
Last Name:EBY
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 1:310 SUNNYVIEW LN
Mailing Address - Street 2:
Mailing Address - City:KALISPELL
Mailing Address - State:MT
Mailing Address - Zip Code:59901-3129
Mailing Address - Country:US
Mailing Address - Phone:406-751-6725
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:406-751-6725
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00042604207R00000X, 207RH0002X
MT10956207RH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8395675Medicaid
2000703OtherINTERNAL ID-MOTOR VEHICLE ID
2000703OtherINTERNAL ID-MOTOR VEHICLE ID
WA8805039Medicare PIN
8805037Medicare ID - Type Unspecified