Provider Demographics
NPI:1013967454
Name:CASS, KIMMIE L (DO)
Entity Type:Individual
Prefix:
First Name:KIMMIE
Middle Name:L
Last Name:CASS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1307 CRANESBILL CT
Mailing Address - Street 2:APT. 101
Mailing Address - City:BELCAMP
Mailing Address - State:MD
Mailing Address - Zip Code:21017-2415
Mailing Address - Country:US
Mailing Address - Phone:410-652-4812
Mailing Address - Fax:
Practice Address - Street 1:1307 CRANESBILL CT
Practice Address - Street 2:APT. 101
Practice Address - City:BELCAMP
Practice Address - State:MD
Practice Address - Zip Code:21017-2415
Practice Address - Country:US
Practice Address - Phone:410-652-4812
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2008-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2002-013492080P0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0204XAllopathic & Osteopathic PhysiciansPediatricsPediatric Emergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC135YJOtherBCBSNC
NC89-135YJMedicaid
SCQ01349Medicaid
I13608Medicare UPIN
NC2402015Medicare PIN