Provider Demographics
NPI:1417985029
Name:CONGER, KENNETH (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:
Last Name:CONGER
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 572
Mailing Address - Street 2:
Mailing Address - City:KOOTENAI
Mailing Address - State:ID
Mailing Address - Zip Code:83840-0572
Mailing Address - Country:US
Mailing Address - Phone:208-263-1060
Mailing Address - Fax:
Practice Address - Street 1:495 FIRESTONE LN
Practice Address - Street 2:
Practice Address - City:SANDPOINT
Practice Address - State:ID
Practice Address - Zip Code:83864-7596
Practice Address - Country:US
Practice Address - Phone:208-263-1060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-30
Last Update Date:2016-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT6472207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
E28048Medicare UPIN
MT81549Medicaid
MT98090OtherBCBS
MT9809Medicare ID - Type Unspecified