Provider Demographics
NPI:1508908245
Name:KIMBALL, AMY S (MD, PHD)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:S
Last Name:KIMBALL
Suffix:
Gender:F
Credentials:MD, PHD
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 62602
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21264-2602
Mailing Address - Country:US
Mailing Address - Phone:410-328-7157
Mailing Address - Fax:410-328-6896
Practice Address - Street 1:22 S GREENE ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-1544
Practice Address - Country:US
Practice Address - Phone:410-328-7157
Practice Address - Fax:410-328-6896
Is Sole Proprietor?:No
Enumeration Date:2007-02-12
Last Update Date:2011-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD68925207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD417539500Medicaid
MDP00797660Medicare PIN
MD155217ZAQPMedicare PIN