Provider Demographics
NPI:1912925165
Name:HAMMERBERG, KIM W (MD)
Entity Type:Individual
Prefix:DR
First Name:KIM
Middle Name:W
Last Name:HAMMERBERG
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:P. O. BOX 8500, LOCKBOX 7642
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19178-7642
Mailing Address - Country:US
Mailing Address - Phone:813-281-8115
Mailing Address - Fax:813-281-8656
Practice Address - Street 1:2211 N. OAK PARK AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60707-3392
Practice Address - Country:US
Practice Address - Phone:773-622-5400
Practice Address - Fax:773-385-5488
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2012-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-058222207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1633878OtherBCBS ILLINOIS
4316748OtherAETNA
IL036058222Medicaid
ILDA4902OtherRR MEDICARE PTAN NUMBER
ILP00408628OtherRR MEDICARE PROVIDER NUMBER
4316748OtherAETNA
IL1633878OtherBCBS ILLINOIS
IL036058222Medicaid
ILK33981Medicare PIN