Provider Demographics
NPI:1073006052
Name:KIDNIE, ROBERT TOMS (MD)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:TOMS
Last Name:KIDNIE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2500 N STATE ST
Mailing Address - Street 2:DEPT OF EMERGENCY MEDICINE
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216
Mailing Address - Country:US
Mailing Address - Phone:443-898-3859
Mailing Address - Fax:601-815-5795
Practice Address - Street 1:2500 N STATE ST
Practice Address - Street 2:DEPT OF EMERGENCY MEDICINE
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-3921
Practice Address - Country:US
Practice Address - Phone:443-898-3859
Practice Address - Fax:601-815-5795
Is Sole Proprietor?:No
Enumeration Date:2018-06-13
Last Update Date:2021-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MS29103207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program