Provider Demographics
NPI:1700984366
Name:BARRACCO, KIMBERLEY LIS (DO)
Entity Type:Individual
Prefix:
First Name:KIMBERLEY
Middle Name:LIS
Last Name:BARRACCO
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:PO BOX 2168
Mailing Address - Street 2:
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29304-2168
Mailing Address - Country:US
Mailing Address - Phone:864-560-4304
Mailing Address - Fax:864-560-4413
Practice Address - Street 1:12 KANAWHA TER
Practice Address - Street 2:
Practice Address - City:SAINT ALBANS
Practice Address - State:WV
Practice Address - Zip Code:25177-2750
Practice Address - Country:US
Practice Address - Phone:304-757-6999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC39076208000000X
WV2064208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
001879423OtherBLUE CROSS BLUE SHEILD
7070869OtherAETNA
SC390767Medicaid
SCSCC510H895OtherMEDICARE PIN
WV3810005951Medicaid
WVWV0220AMedicare PIN
I63129Medicare UPIN
WV4195312Medicare PIN
WV4195314Medicare PIN