Provider Demographics
NPI:1184732356
Name:WEBER, KIM M (MD)
Entity type:Individual
Prefix:DR
First Name:KIM
Middle Name:M
Last Name:WEBER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:KIM
Other - Middle Name:M
Other - Last Name:MANNING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1100 REID PARKWAY
Mailing Address - Street 2:MEDICAL STAFF SERVICES
Mailing Address - City:RICHMOND
Mailing Address - State:IN
Mailing Address - Zip Code:47374
Mailing Address - Country:US
Mailing Address - Phone:765-935-8802
Mailing Address - Fax:765-983-3219
Practice Address - Street 1:1380 CHESTER BLVD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:IN
Practice Address - Zip Code:47374-1907
Practice Address - Country:US
Practice Address - Phone:765-983-3300
Practice Address - Fax:765-983-7916
Is Sole Proprietor?:No
Enumeration Date:2006-08-28
Last Update Date:2021-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01045014207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200077300AMedicaid
IN258610AOtherMEDICARE PTAN
F73366Medicare UPIN
IN200077300AMedicaid