Provider Demographics
NPI:1922020767
Name:ANDERSON, KIMBERLEY ANN (MD)
Entity Type:Individual
Prefix:
First Name:KIMBERLEY
Middle Name:ANN
Last Name:ANDERSON
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 1:7500 HANOVER PKWY
Mailing Address - Street 2:STE 104
Mailing Address - City:GREENBELT
Mailing Address - State:MD
Mailing Address - Zip Code:20770-2010
Mailing Address - Country:US
Mailing Address - Phone:301-220-0672
Mailing Address - Fax:
Practice Address - Street 1:7500 HANOVER PKWY
Practice Address - Street 2:STE 104
Practice Address - City:GREENBELT
Practice Address - State:MD
Practice Address - Zip Code:20770-2010
Practice Address - Country:US
Practice Address - Phone:301-220-0672
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-24
Last Update Date:2014-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0034747208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD010167200Medicaid
MD010167200Medicaid
DC020153B74Medicare PIN