Provider Demographics
NPI:1316040926
Name:KIMBALL, JIMMY CLARKE (MD)
Entity Type:Individual
Prefix:
First Name:JIMMY
Middle Name:CLARKE
Last Name:KIMBALL
Suffix:
Gender:M
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 15004
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37901-5004
Mailing Address - Country:US
Mailing Address - Phone:865-541-8895
Mailing Address - Fax:865-633-4808
Practice Address - Street 1:4600 ASHEVILLE HWY
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37914-3665
Practice Address - Country:US
Practice Address - Phone:865-522-8114
Practice Address - Fax:866-550-6541
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN13576208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ007841Medicaid
TN6165200OtherBLUE CROSS BLUE SHIELD PROVIDER ID
TN3088496OtherBCBS