Provider Demographics
NPI:1164665428
Name:MILLER-HAMMOND, KIMBERLY EVONNE (MD)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:EVONNE
Last Name:MILLER-HAMMOND
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 1:1 GOOD SAMARITAN WAY
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IL
Mailing Address - Zip Code:62864-2402
Mailing Address - Country:US
Mailing Address - Phone:770-617-5556
Mailing Address - Fax:
Practice Address - Street 1:1 GOOD SAMARITAN WAY
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-2402
Practice Address - Country:US
Practice Address - Phone:770-617-5556
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-15
Last Update Date:2022-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCTL37495208600000X
IL036159613208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery