Provider Demographics
NPI:1366677676
Name:KILGORE, KIMBERLY M (MD)
Entity Type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:M
Last Name:KILGORE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 743904
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-3904
Mailing Address - Country:US
Mailing Address - Phone:803-296-7320
Mailing Address - Fax:803-296-7330
Practice Address - Street 1:3600 FOREST DR STE 300
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29204-4057
Practice Address - Country:US
Practice Address - Phone:803-749-5101
Practice Address - Fax:803-933-3045
Is Sole Proprietor?:No
Enumeration Date:2009-05-16
Last Update Date:2020-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK26381207Q00000X
SC61239207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC612395Medicaid