1194796813 NPI number — DR. JAIME LYN KIBLER-MCCORMICK D.O.

Table of content: DR. JAIME LYN KIBLER-MCCORMICK D.O. (NPI 1194796813)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194796813 NPI number — DR. JAIME LYN KIBLER-MCCORMICK D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KIBLER-MCCORMICK
Provider First Name:
JAIME
Provider Middle Name:
LYN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.O.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CORY
Provider Other First Name:
JAIME
Provider Other Middle Name:
KIBLER
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
D.O.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1194796813
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/09/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 746638
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30374-6638
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-202-1032
Provider Business Mailing Address Fax Number:
904-376-4107

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
30 ARDISIA LANE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ST. JOHNS
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32259
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-287-2794
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/30/2006

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: 207Q00000X , with the licence number:  OS9402 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 009172600 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: P01321205 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 111607300 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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