1104005917 NPI number — KIMBERLY A PUMMILL MD PC

Table of content: (NPI 1104005917)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104005917 NPI number — KIMBERLY A PUMMILL MD PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KIMBERLY A PUMMILL MD PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
GRAND BLANC PLASTIC SURGERY
Provider Other Organization Name Type Code:
5
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:
1104005917
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/27/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3595 GENESYS PKWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRAND BLANC
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48439-7335
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
810-606-7888
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3595 GENESYS PKWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRAND BLANC
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48439-7335
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
810-606-7888
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/29/2007

Additional Information

Authorized Official

Authorized Official Last Name:
PUMMILL
Authorized Official First Name:
KIMBERLY
Authorized Official Middle Name:
ANN
Authorized Official Title or Position:
DOCTOR
Authorized Official Telephone Number:
810-606-7888

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  4301070280 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0993473 . This is a "HEALTH PLUS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 7319368 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0251130 . This is a "BLUE CROSS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 14465 . This is a "MCARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 6U4349 . This is a "HAP" identifier . This identifiers is of the category "OTHER".




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