Provider Demographics
NPI:1548226962
Name:RUSSELL, KIMBERLY J (MD)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:J
Last Name:RUSSELL
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 1:115 OVERLAND DR
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:SC
Mailing Address - Zip Code:29646-4053
Mailing Address - Country:US
Mailing Address - Phone:864-227-6641
Mailing Address - Fax:864-227-3953
Practice Address - Street 1:115 OVERLAND DR
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:SC
Practice Address - Zip Code:29646-4053
Practice Address - Country:US
Practice Address - Phone:864-227-6641
Practice Address - Fax:864-227-3953
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2021-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC19430207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCT35726Medicaid
SCG55983Medicare UPIN
SCG559834755Medicare PIN
SC9337Medicare PIN
SCGP5708Medicaid