Provider Demographics
NPI:1801972674
Name:BASS, KIMBERLY SUSAN (MD)
Entity type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:SUSAN
Last Name:BASS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1347 LARPENTEUR AVE W
Mailing Address - Street 2:
Mailing Address - City:FALCON HEIGHTS
Mailing Address - State:MN
Mailing Address - Zip Code:55113-6302
Mailing Address - Country:US
Mailing Address - Phone:651-558-2020
Mailing Address - Fax:651-487-2369
Practice Address - Street 1:1347 LARPENTEUR AVE W
Practice Address - Street 2:
Practice Address - City:FALCON HEIGHTS
Practice Address - State:MN
Practice Address - Zip Code:55113-6302
Practice Address - Country:US
Practice Address - Phone:651-558-2020
Practice Address - Fax:651-487-2369
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2009-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN34550174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNP00375969OtherRAILROAD MEDICARE
MNP00375969OtherRAILROAD MEDICARE