Provider Demographics
NPI:1205922879
Name:EGLI, KENNETH J (MD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:J
Last Name:EGLI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5615 DUNBARTON AVE
Mailing Address - Street 2:
Mailing Address - City:PASCO
Mailing Address - State:WA
Mailing Address - Zip Code:99301-8216
Mailing Address - Country:US
Mailing Address - Phone:509-222-1275
Mailing Address - Fax:
Practice Address - Street 1:8508 W GAGE BLVD STE A101
Practice Address - Street 2:
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99336-8106
Practice Address - Country:US
Practice Address - Phone:877-522-1275
Practice Address - Fax:833-888-7145
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2020-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00041379207P00000X, 2083A0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083A0300XAllopathic & Osteopathic PhysiciansPreventive MedicineAddiction Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8358749Medicaid
WA0227845OtherLIWA
WA911348529OtherOTHER INS #
WA0227845OtherLIWA
WAH96673Medicare UPIN