Provider Demographics
NPI:1033149570
Name:ROSS, KIMRA (MD)
Entity Type:Individual
Prefix:
First Name:KIMRA
Middle Name:
Last Name:ROSS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3810
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64803
Mailing Address - Country:US
Mailing Address - Phone:417-782-9393
Mailing Address - Fax:417-782-4659
Practice Address - Street 1:1030 MCINTOSH CIR
Practice Address - Street 2:STE 2
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804-3642
Practice Address - Country:US
Practice Address - Phone:417-782-9393
Practice Address - Fax:417-782-4659
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2009-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR1P51208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO149422OtherANTHEM
OK100027400AMedicaid
KS100125890BMedicaid
MO203010707Medicaid
KS100125890BMedicaid