Healthcare Provider Details

I. General information

NPI: 1205812732
Provider Name (Legal Business Name): STEPHEN JAY KINSLEY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 12/16/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

USCG SECTOR-AIR STATION NORTH BEND 2000 CONNECTICUT AVE
NORTH BEND OR
97459
US

IV. Provider business mailing address

67266 WILD RHODIE DR
NORTH BEND OR
97459-8681
US

V. Phone/Fax

Practice location:
  • Phone: 541-756-9237
  • Fax:
Mailing address:
  • Phone: 541-756-2421
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number35-05-7309
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: