1336109990 NPI number — KIMBERLEY PRATER M.D.

Table of content: KIMBERLEY PRATER M.D. (NPI 1336109990)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336109990 NPI number — KIMBERLEY PRATER M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PRATER
Provider First Name:
KIMBERLEY
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ALEXANDER
Provider Other First Name:
KIMBERLEY
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.D.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1336109990
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/03/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 3262
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPRINGFIELD
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
65808-3262
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
417-885-3888
Provider Business Mailing Address Fax Number:
417-881-7268

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3850 S NATIONAL AVE
Provider Second Line Business Practice Location Address:
SUITE 300
Provider Business Practice Location Address City Name:
SPRINGFIELD
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65807-5287
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
417-269-6170
Provider Business Practice Location Address Fax Number:
417-269-6992
Provider Enumeration Date:
03/27/2006

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: 2085R0202X , with the licence number:  36418 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1256 . This is a "BLUE" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: P00807644 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 300035139 . This is a "RRR MEDICARE" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 202564407 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 116201001 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".




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