Provider Demographics
NPI:1629162219
Name:HAM, KIMBERLEY RHODES (MD)
Entity Type:Individual
Prefix:
First Name:KIMBERLEY
Middle Name:RHODES
Last Name:HAM
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 1:2510 HWY 127
Mailing Address - Street 2:HOUSTON LAKE MEDSTOP
Mailing Address - City:KATHLEEN
Mailing Address - State:GA
Mailing Address - Zip Code:31047
Mailing Address - Country:US
Mailing Address - Phone:478-975-6800
Mailing Address - Fax:478-975-6814
Practice Address - Street 1:2510 HWY 127
Practice Address - Street 2:HOUSTON LAKE MEDSTOP
Practice Address - City:KATHLEEN
Practice Address - State:GA
Practice Address - Zip Code:31047
Practice Address - Country:US
Practice Address - Phone:478-975-6800
Practice Address - Fax:478-975-6814
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2015-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA050375207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00918882AMedicaid
GA08BBVRXMedicare ID - Type Unspecified
GAH73207Medicare UPIN