Provider Demographics
NPI:1780660068
Name:HALL, KIM M (MD)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:M
Last Name:HALL
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 1:617 OLD SYMSONIA RD
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:KY
Mailing Address - Zip Code:42025-1365
Mailing Address - Country:US
Mailing Address - Phone:270-527-2411
Mailing Address - Fax:270-527-8734
Practice Address - Street 1:617 OLD SYMSONIA RD
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:KY
Practice Address - Zip Code:42025-1365
Practice Address - Country:US
Practice Address - Phone:270-527-2411
Practice Address - Fax:270-527-8734
Is Sole Proprietor?:No
Enumeration Date:2005-12-19
Last Update Date:2009-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY41423207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100189760AMedicaid
041700Medicare ID - Type Unspecified
KY3322169Medicare PIN
KS100189760AMedicaid