Provider Demographics
NPI:1881699759
Name:HAMELBERG, KIM SCOTT (MD)
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:SCOTT
Last Name:HAMELBERG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:495 COOPER RD
Mailing Address - Street 2:STE 430
Mailing Address - City:WESTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43081-8723
Mailing Address - Country:US
Mailing Address - Phone:614-508-0001
Mailing Address - Fax:614-508-0008
Practice Address - Street 1:495 COOPER RD
Practice Address - Street 2:STE 430
Practice Address - City:WESTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:43081-8723
Practice Address - Country:US
Practice Address - Phone:614-508-0001
Practice Address - Fax:614-508-0008
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-16
Last Update Date:2007-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35057243208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0820946Medicaid
OH0622479Medicare PIN
OHA83178Medicare UPIN