Provider Demographics
NPI:1285669382
Name:KIMMEY, MICHAEL B (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:B
Last Name:KIMMEY
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 1:1112 6TH AVE
Mailing Address - Street 2:200
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-4040
Mailing Address - Country:US
Mailing Address - Phone:253-272-8664
Mailing Address - Fax:253-404-1352
Practice Address - Street 1:1112 6TH AVE
Practice Address - Street 2:200
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-4040
Practice Address - Country:US
Practice Address - Phone:253-272-8664
Practice Address - Fax:253-404-1352
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2008-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00018337207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA203847OtherLABOR & INDUSTRIES
WA8147407Medicaid
1122KIOtherREGENCE BLUE SHIELD
P00305386Medicare PIN
8857490Medicare ID - Type UnspecifiedMEDICARE
WA8147407Medicaid