Provider Demographics
NPI:1194753293
Name:RUSSELL, KIMBERLY ANN (MD)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ANN
Last Name:RUSSELL
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 1:2717 EAST OAKLAND AVENUE
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37601-1843
Mailing Address - Country:US
Mailing Address - Phone:423-926-2358
Mailing Address - Fax:423-926-2680
Practice Address - Street 1:300 LABORATORY RD
Practice Address - Street 2:
Practice Address - City:OAK RIDGE
Practice Address - State:TN
Practice Address - Zip Code:37830
Practice Address - Country:US
Practice Address - Phone:865-482-7698
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-28
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN36903207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3885411Medicaid
TNP00040818OtherRR MEDICARE PIN
TN3717547Medicare ID - Type UnspecifiedLEGACY GROUP
TN3885411Medicaid
G40687Medicare UPIN