Healthcare Provider Details

I. General information

NPI: 1619971298
Provider Name (Legal Business Name): KELLY A. MCGINNIS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/10/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17700 SE 272ND ST STE 175
COVINGTON WA
98042-4951
US

IV. Provider business mailing address

PO BOX 97115
LAKEWOOD WA
98497-0115
US

V. Phone/Fax

Practice location:
  • Phone: 253-372-7200
  • Fax:
Mailing address:
  • Phone: 253-588-7911
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberMD00025660
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: