Provider Demographics
NPI:1770612467
Name:EDWARDS-HALL, KIMBERLY ANN (MD)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ANN
Last Name:EDWARDS-HALL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:ANN
Other - Last Name:EDWARDS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:110 OAK HILL BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30265-2313
Mailing Address - Country:US
Mailing Address - Phone:770-304-0987
Mailing Address - Fax:770-916-4460
Practice Address - Street 1:110 OAK HILL BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30265-2313
Practice Address - Country:US
Practice Address - Phone:770-304-0987
Practice Address - Fax:770-916-4460
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2015-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA031414207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00431989UMedicaid
GA511I110610Medicare PIN
GAF29784Medicare UPIN