Provider Demographics
NPI:1659427144
Name:KIMMAR MEDICAL ASSOCIATES
Entity Type:Organization
Organization Name:KIMMAR MEDICAL ASSOCIATES
Other - Org Name:KIMMAR MEDICAL ASSOCIATES, LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:ADMINISTRATO
Authorized Official - Prefix:MISS
Authorized Official - First Name:KIM
Authorized Official - Middle Name:S
Authorized Official - Last Name:SWAIN
Authorized Official - Suffix:
Authorized Official - Credentials:ADMINISTRATOR
Authorized Official - Phone:410-987-6430
Mailing Address - Street 1:7231 RITCHIE HWY
Mailing Address - Street 2:SUITE B
Mailing Address - City:GLEN BURNIE
Mailing Address - State:MD
Mailing Address - Zip Code:21061
Mailing Address - Country:US
Mailing Address - Phone:410-987-6430
Mailing Address - Fax:410-987-6433
Practice Address - Street 1:7231 RITCHIE HWY
Practice Address - Street 2:SUITE B
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21061
Practice Address - Country:US
Practice Address - Phone:410-987-6430
Practice Address - Fax:410-987-6433
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-26
Last Update Date:2020-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR2340251J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251J00000XAgenciesNursing Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD409296100Medicaid
MD4092961P00Medicaid