Provider Demographics
NPI:1306845565
Name:GUSH, KIMBERLY ANN (MD)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ANN
Last Name:GUSH
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 1:300 MARKET ST STE 112
Mailing Address - Street 2:
Mailing Address - City:CHAPEL HILL
Mailing Address - State:NC
Mailing Address - Zip Code:27516-4493
Mailing Address - Country:US
Mailing Address - Phone:919-969-9611
Mailing Address - Fax:919-969-9615
Practice Address - Street 1:300 MARKET ST STE 112
Practice Address - Street 2:
Practice Address - City:CHAPEL HILL
Practice Address - State:NC
Practice Address - Zip Code:27516-4493
Practice Address - Country:US
Practice Address - Phone:919-969-9611
Practice Address - Fax:919-969-9615
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2005-00670208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5902692Medicaid
NCI48445Medicare UPIN