1831154574 NPI number — KIMBERLY J HUMULOCK DO

Table of content: KIMBERLY J HUMULOCK DO (NPI 1831154574)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1831154574 NPI number — KIMBERLY J HUMULOCK DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HUMULOCK
Provider First Name:
KIMBERLY
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
F

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:
1831154574
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/31/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
190 COMMERCE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WARWICK
Provider Business Mailing Address State Name:
RI
Provider Business Mailing Address Postal Code:
02886-2430
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
401-921-5970
Provider Business Mailing Address Fax Number:
401-921-5973

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
190 COMMERCE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WARWICK
Provider Business Practice Location Address State Name:
RI
Provider Business Practice Location Address Postal Code:
02886-2430
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
401-492-1597
Provider Business Practice Location Address Fax Number:
401-921-5973
Provider Enumeration Date:
04/18/2006

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: 207R00000X , with the licence number:  DO00521 , registered in the state of RI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 7936235 . This is a "AETNA HEALTH CARE" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".
  • Identifier: 454709 . This is a "TUFTS HEALTH PLAN" identifier , issued by the state of ( PR ) . This identifiers is of the category "OTHER".
  • Identifier: 04-0336 . This is a "UNITEDHEALTH CARE" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".
  • Identifier: 407435 . This is a "BLUE CHIP" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".
  • Identifier: 22405-7 . This is a "BLUE CROSS & BLUE SHIELD" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".
  • Identifier: 9022405 , issued by the state of ( RI ) . This identifiers is of the category "MEDICAID".




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