1306836705 NPI number — MARK T EGGLESTON MD

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306836705 NPI number — MARK T EGGLESTON MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EGGLESTON
Provider First Name:
MARK
Provider Middle Name:
T
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1306836705
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/30/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
500 PORT DRIVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLARKSTON
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
99403-1835
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-758-8811
Provider Business Mailing Address Fax Number:
509-751-1188

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
500 PORT DRIVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLARKSTON
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99403-1835
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-758-8811
Provider Business Practice Location Address Fax Number:
509-751-1188
Provider Enumeration Date:
10/26/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207W00000X , with the licence number:  MD00039323 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207W00000X , with the licence number: M8239 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 000010033114 . This is a "REGENCE BLUE SHIELD OF IDAHO" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 0152789 . This is a "LABOR & INDUSTRY" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 806011100 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: MXXPR0054708 . This is a "MOLINA HEALTHCARE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 0000100033114 . This is a "FEDERAL BLUE CROSS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 24509 . This is a "GROUP HEALTH COOPERATIVE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: BYHD5 . This is a "BLUE CROSS OF IDAHO" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 000010145029 . This is a "REGENCE BLUE SHIELD OF IDAHO" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 8293425 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8928983 . This is a "CRIME VICTIMES COMPENSATION ACT" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 42663 . This is a "BLUE CROSS OF IDAHO" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".




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