Provider Demographics
NPI:1689857328
Name:GLENN P KIMBALL
Entity Type:Organization
Organization Name:GLENN P KIMBALL
Other - Org Name:GLENN P KIMBALL JR MD LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:P
Authorized Official - Last Name:KIMBALL
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:978-374-4258
Mailing Address - Street 1:680 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HAVERHILL
Mailing Address - State:MA
Mailing Address - Zip Code:01830-2644
Mailing Address - Country:US
Mailing Address - Phone:978-374-4258
Mailing Address - Fax:
Practice Address - Street 1:680 MAIN ST
Practice Address - Street 2:
Practice Address - City:HAVERHILL
Practice Address - State:MA
Practice Address - Zip Code:01830-2644
Practice Address - Country:US
Practice Address - Phone:978-374-4258
Practice Address - Fax:978-374-4982
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-17
Last Update Date:2018-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA57624207W00000X
MA1177510001332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1177510001Medicare NSC
MAGLM20934Medicare PIN