Provider Demographics
NPI:1114005683
Name:KAISER, KIM JOHN
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:JOHN
Last Name:KAISER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37 CARDINAL RD
Mailing Address - Street 2:
Mailing Address - City:EAST LYME
Mailing Address - State:CT
Mailing Address - Zip Code:06333-1045
Mailing Address - Country:US
Mailing Address - Phone:860-691-3033
Mailing Address - Fax:860-691-3006
Practice Address - Street 1:37 CARDINAL RD
Practice Address - Street 2:
Practice Address - City:EAST LYME
Practice Address - State:CT
Practice Address - Zip Code:06333-1045
Practice Address - Country:US
Practice Address - Phone:860-691-3033
Practice Address - Fax:860-691-3006
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2013-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT06-1357833171W00000X
332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004101953Medicaid
CT0559930001Medicare ID - Type Unspecified