Provider Demographics
NPI:1245230523
Name:REGER, KENNETH M (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:M
Last Name:REGER
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 26730
Mailing Address - Street 2:
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98093-3730
Mailing Address - Country:US
Mailing Address - Phone:253-661-1700
Mailing Address - Fax:253-661-4565
Practice Address - Street 1:533 S 336TH ST
Practice Address - Street 2:SUITE C
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003-6329
Practice Address - Country:US
Practice Address - Phone:253-661-1700
Practice Address - Fax:253-661-4565
Is Sole Proprietor?:No
Enumeration Date:2005-07-28
Last Update Date:2012-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD000228882085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1005131Medicaid
WAA06856Medicare UPIN
AB38680Medicare PIN
000159712Medicare PIN
8854134Medicare PIN