Provider Demographics
NPI:1194455626
Name:KIMBERLY HENDERSON MD PC
Entity Type:Organization
Organization Name:KIMBERLY HENDERSON MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR, PAYER CONTRACTING
Authorized Official - Prefix:
Authorized Official - First Name:DEVION
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:424-326-8711
Mailing Address - Street 1:33 ARCH ST FL 17
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02110-1424
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:80 WARREN ST APT 32
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10007-1038
Practice Address - Country:US
Practice Address - Phone:310-846-8675
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-06-16
Last Update Date:2022-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty