Provider Demographics
NPI:1578557559
Name:PRYOR, KIMBERLEY N (DO)
Entity Type:Individual
Prefix:
First Name:KIMBERLEY
Middle Name:N
Last Name:PRYOR
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:KIMBERLEY
Other - Middle Name:
Other - Last Name:TATUM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:1080 PEACHTREE ST NE UNIT 1910
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30309-6825
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:550 PEACHTREE ST NE RM 3356
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30308-2247
Practice Address - Country:US
Practice Address - Phone:404-686-6730
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-07
Last Update Date:2018-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101014424208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI70-0-F32947-0OtherBCBS CPIN #
MIKT014424OtherBCBSM
MI1578557559OtherNPI #
MI4846727Medicaid
H71738Medicare UPIN
MI70-0-F32947-0OtherBCBS CPIN #