Provider Demographics
NPI:1689671406
Name:CROSS, KIMBERLY SUE (MD)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:SUE
Last Name:CROSS
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 1:800 PENNSYLVANIA AVE
Mailing Address - Street 2:CHILDREN'S MEDICINE CENTER
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25302
Mailing Address - Country:US
Mailing Address - Phone:304-388-2525
Mailing Address - Fax:304-388-2537
Practice Address - Street 1:800 PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25302-3351
Practice Address - Country:US
Practice Address - Phone:304-388-2526
Practice Address - Fax:304-388-2537
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2019-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV19689207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV7354454OtherAETNA
WV3002030000Medicaid
WV001721334OtherMS BCBS
WV4089841Medicare PIN
WV7354454OtherAETNA