Sam Child Eggertsen, MD

Primary specialty

Family Medicine PhysicianTaxonomy code 207Q00000X

License

MD00016014 Issued in WA

Practice address

6016 NE Bothell Way
Ste G
Kenmore, WA 98028-9403

Phone

(425) 486-0658

NPI assigned

Jul 12, 2005

Last updated

Jul 8, 2007By the provider in NPPES

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

HHS exclusion list flag

CMS’s directory marks this NPI as on an HHS exclusion list; no matching OIG record was found. The OIG exclusions file (LEIE) holds no record for this NPI, and the directory does not say which list the flag comes from. How exclusions are shown Confirm with the OIG exclusions search.

Credentials

Doctor of Medicine

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1121126400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1183852800000",
    "number": "1457359507",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "403 E MEEKER ST",
            "address_2": "STE 300",
            "city": "KENT",
            "state": "WA",
            "postal_code": "980305904"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "6016 NE BOTHELL WAY",
            "address_2": "STE G",
            "city": "KENMORE",
            "state": "WA",
            "postal_code": "980289403",
            "telephone_number": "425-486-0658"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "EGGERTSEN",
        "first_name": "SAM",
        "middle_name": "CHILD",
        "credential": "MD",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2005-07-12",
        "last_updated": "2007-07-08",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "WA",
            "license": "MD00016014",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Family Medicine Physician in Kenmore, WA
• Providers in Kenmore, WA by specialty
• Family Medicine Physician in Washington

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 8, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.