Provider Demographics
NPI:1346338456
Name:KININGHAM, ROBERT B (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:B
Last Name:KININGHAM
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 1:3621 S STATE ST
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48108-1633
Mailing Address - Country:US
Mailing Address - Phone:734-647-5299
Mailing Address - Fax:
Practice Address - Street 1:24 FRANK LLOYD WRIGHT DR
Practice Address - Street 2:LOBBY H
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48105-9484
Practice Address - Country:US
Practice Address - Phone:734-647-5640
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2019-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301054682207QS0010X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2956800Medicaid
MIF48164Medicare UPIN
MI0H17630031Medicare ID - Type Unspecified