Provider Demographics
NPI:1902816606
Name:GRILL, KIMBERLY ANN (DO)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ANN
Last Name:GRILL
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:10863 PARK BLVD STE 4
Mailing Address - Street 2:
Mailing Address - City:SEMINOLE
Mailing Address - State:FL
Mailing Address - Zip Code:33772-5423
Mailing Address - Country:US
Mailing Address - Phone:727-545-4700
Mailing Address - Fax:727-545-4755
Practice Address - Street 1:5425 PARK ST N
Practice Address - Street 2:SUITE 5W
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33709-7062
Practice Address - Country:US
Practice Address - Phone:727-545-4700
Practice Address - Fax:727-545-4755
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-08
Last Update Date:2019-05-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FL0S 9367207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLI69198Medicare UPIN