Provider Demographics
NPI:1336797794
Name:EIDSON, KIMBERLY M
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:M
Last Name:EIDSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:235 E CHICAGO ST STE 1
Mailing Address - Street 2:
Mailing Address - City:COLDWATER
Mailing Address - State:MI
Mailing Address - Zip Code:49036-1789
Mailing Address - Country:US
Mailing Address - Phone:517-279-8465
Mailing Address - Fax:
Practice Address - Street 1:3238 CAPITAL AVE SW
Practice Address - Street 2:
Practice Address - City:BATTLE CREEK
Practice Address - State:MI
Practice Address - Zip Code:49015-4302
Practice Address - Country:US
Practice Address - Phone:269-979-6432
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-29
Last Update Date:2022-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704265679176B00000X, 367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No176B00000XOther Service ProvidersMidwife