Provider Demographics
NPI:1497064349
Name:ELI KACZYNSKI MD PS
Entity Type:Organization
Organization Name:ELI KACZYNSKI MD PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CORPORATE PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ELI
Authorized Official - Middle Name:NMI
Authorized Official - Last Name:KACZYNSKI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:509-783-3161
Mailing Address - Street 1:2529 W FALLS AVE
Mailing Address - Street 2:
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99336-3041
Mailing Address - Country:US
Mailing Address - Phone:509-783-3161
Mailing Address - Fax:509-783-3163
Practice Address - Street 1:2529 W FALLS AVE
Practice Address - Street 2:
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99336-3041
Practice Address - Country:US
Practice Address - Phone:509-783-3161
Practice Address - Fax:509-783-3163
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-27
Last Update Date:2015-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00016765207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0017179OtherST. IND
WA1364306Medicaid
WA756181836OtherMEDICARE RAILROAD
WA1364306Medicaid
WAG000300775Medicare Oscar/Certification