MEDICARE: CRISWELL ALLEN KENNEDY M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208D00000X	General Practice Physician	MD00017804	WA

General Provider Information

NPI Number	:	1912122847
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CRISWELL ALLEN KENNEDY M.D.

Provider Business Mailing Address
First Line	:	24128 E ALKI LN
Second Line	:
City	:	LIBERTY LAKE
State	:	WA
Zip	:	99019-9447
Country	:	US
Telephone Number	:	509-255-5065
Fax Number	:	509-477-6352

Provider Business Practice Location Address
First Line	:	24128 E ALKI LN
Second Line	:
City	:	LIBERTY LAKE
State	:	WA
Zip	:	99019-9447
Country	:	US
Telephone Number	:	509-255-5065
Fax Number	:	509-477-6352

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/16/2007
Last Update Date	:	07/08/2007

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