Provider Demographics
NPI:1962455592
Name:RUSSELL, KIMBERLY ANN (MD)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ANN
Last Name:RUSSELL
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 1:901 E. 104TH ST.
Mailing Address - Street 2:MAILSTOP 400N
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64131-4517
Mailing Address - Country:US
Mailing Address - Phone:816-502-7104
Mailing Address - Fax:816-932-9670
Practice Address - Street 1:12541 FOSTER ST
Practice Address - Street 2:SUITE 300
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66213-2630
Practice Address - Country:US
Practice Address - Phone:913-317-3200
Practice Address - Fax:913-317-3218
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2018-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS0428043207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100339820CMedicaid
G93000006Medicare PIN
G94350Medicare UPIN