Provider Demographics
NPI:1609961259
Name:KENNETH R. KOSKELLA, MD, INC
Entity Type:Organization
Organization Name:KENNETH R. KOSKELLA, MD, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:VICKI
Authorized Official - Middle Name:B
Authorized Official - Last Name:SPLINTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-479-2544
Mailing Address - Street 1:2500 CHERRY AVENUE
Mailing Address - Street 2:SUITE 304
Mailing Address - City:BREMERTON
Mailing Address - State:WA
Mailing Address - Zip Code:98310-4202
Mailing Address - Country:US
Mailing Address - Phone:360-479-2544
Mailing Address - Fax:360-479-7416
Practice Address - Street 1:2600 WHEATON WAY
Practice Address - Street 2:#304
Practice Address - City:BREMERTON
Practice Address - State:WA
Practice Address - Zip Code:98310-3319
Practice Address - Country:US
Practice Address - Phone:360-479-2003
Practice Address - Fax:360-479-7416
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA00038111174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty