Provider Demographics
NPI:1215977293
Name:RICHARDSON, KIMBERLY A (MD)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:A
Last Name:RICHARDSON
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 1:210 MALL BLVD
Mailing Address - Street 2:STE 102
Mailing Address - City:KING OF PRUSSIA
Mailing Address - State:PA
Mailing Address - Zip Code:19406-3260
Mailing Address - Country:US
Mailing Address - Phone:610-265-0726
Mailing Address - Fax:610-265-3132
Practice Address - Street 1:210 MALL BLVD
Practice Address - Street 2:STE 102
Practice Address - City:KING OF PRUSSIA
Practice Address - State:PA
Practice Address - Zip Code:19406-3260
Practice Address - Country:US
Practice Address - Phone:610-265-0726
Practice Address - Fax:610-265-3132
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2019-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD072499L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA7321274OtherAETNA PPO
PA1012799110001Medicaid
PA1132457OtherAETNA HMO
PA30025497OtherKEYSTONE MERCY
PA2403640000OtherAMERIHEALTH/INTERCOUNTY
PA7709703OtherCIGNA HMO/PPO
PA1736726OtherHIGHMARK BLUE SHIELD
PA10435887OtherCAQH ID#
PA2403640000OtherIBC - PC/KHPE
PA10435887OtherCAQH ID#
PA1012799110001Medicaid