1255656070 NPI number — MS. KIMBERLY A BEAN NP

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 1255656070 NPI number — MS. KIMBERLY A BEAN NP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BEAN
Provider First Name:
KIMBERLY
Provider Middle Name:
A
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
NP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
PLOUSSAS
Provider Other First Name:
KIMBERLY
Provider Other Middle Name:
A
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
NP
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1255656070
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/30/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
955 RIBAUT RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BEAUFORT
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29902-5454
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
843-522-7843
Provider Business Mailing Address Fax Number:
843-522-5945

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
122 OKATIE CENTER BLVD N STE 310
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OKATIE
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29909-3782
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-706-8690
Provider Business Practice Location Address Fax Number:
844-295-9802
Provider Enumeration Date:
04/05/2010

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: 363L00000X , with the licence number:  4230 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: SCB8689125 . This is a "MEDICARE PTAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: P01510934 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: NP1618 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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