Provider Demographics
NPI:1033375605
Name:POWELL, KIMBERLY NICHOLE (MD)
Entity Type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:NICHOLE
Last Name:POWELL
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 19635
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62794-9635
Mailing Address - Country:US
Mailing Address - Phone:217-545-8000
Mailing Address - Fax:217-757-6654
Practice Address - Street 1:415 N 9TH ST
Practice Address - Street 2:SUITE 4W16
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702-5303
Practice Address - Country:US
Practice Address - Phone:217-545-8000
Practice Address - Fax:217-757-6654
Is Sole Proprietor?:No
Enumeration Date:2008-08-04
Last Update Date:2016-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011009284208000000X, 2080P0204X
IL0361408052080P0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0203XAllopathic & Osteopathic PhysiciansPediatricsPediatric Critical Care Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080P0204XAllopathic & Osteopathic PhysiciansPediatricsPediatric Emergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL$$$$$$$$$Medicaid
IL$$$$$$$$$Medicaid