Provider Demographics
NPI:1982847042
Name:CARROLL, KIMBERLY JEANNE (MD)
Entity Type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:JEANNE
Last Name:CARROLL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:670 MASON RIDGE CENTER DR
Mailing Address - Street 2:STE 300
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8573
Mailing Address - Country:US
Mailing Address - Phone:314-996-7930
Mailing Address - Fax:314-996-7935
Practice Address - Street 1:3023 N BALLAS RD STE 500
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63131-2359
Practice Address - Country:US
Practice Address - Phone:314-996-7930
Practice Address - Fax:314-996-7935
Is Sole Proprietor?:No
Enumeration Date:2009-04-19
Last Update Date:2021-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015027133207RR0500X
WI56232207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1982847042Medicaid
WI1982847042Medicaid
WI68086 2544Medicare PIN