1548437718 NPI number — MATTHEW D. KIMBALL MD

Table of content: ADRIANA JOVANOV (NPI 1639810658)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548437718 NPI number — MATTHEW D. KIMBALL MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KIMBALL
Provider First Name:
MATTHEW
Provider Middle Name:
D.
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:
1548437718
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/05/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2151 OLD ROCKY RIDGE RD
Provider Second Line Business Mailing Address:
SUITE 106
Provider Business Mailing Address City Name:
BIRMINGHAM
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
35216-7235
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
205-989-1080
Provider Business Mailing Address Fax Number:
205-989-1087

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
315 W HICKORY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SYLACAUGA
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
35150-2913
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
256-401-4605
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/15/2008

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: 207L00000X , with the licence number:  MD.31741 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 06037 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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