Provider Demographics
NPI:1548399652
Name:KIM M ALMODOVAR MD PLC
Entity Type:Organization
Organization Name:KIM M ALMODOVAR MD PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KIM
Authorized Official - Middle Name:M
Authorized Official - Last Name:ALMODOVAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-656-4225
Mailing Address - Street 1:1460 WALTON BLVD
Mailing Address - Street 2:SUITE 209
Mailing Address - City:ROCHESTER HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48309-1768
Mailing Address - Country:US
Mailing Address - Phone:248-656-4225
Mailing Address - Fax:248-656-4250
Practice Address - Street 1:1460 WALTON BLVD
Practice Address - Street 2:SUITE 209
Practice Address - City:ROCHESTER HILLS
Practice Address - State:MI
Practice Address - Zip Code:48309-1768
Practice Address - Country:US
Practice Address - Phone:248-656-4225
Practice Address - Fax:248-656-4250
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-05
Last Update Date:2023-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI053408207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4177912Medicaid
MI0M96440OtherMEDICARE PTAN
0M96440OtherMEDICARE PROVIDER TRANSACTION ACCESS NUMBER
MI0M96440Medicare ID - Type Unspecified
MI4177912Medicaid