Provider Demographics
NPI:1316277858
Name:KIMBERLYNN R. RICHARDS, MD, PC
Entity type:Organization
Organization Name:KIMBERLYNN R. RICHARDS, MD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KIMBERLYNN
Authorized Official - Middle Name:ROCHELLE
Authorized Official - Last Name:RICHARDS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:404-272-1724
Mailing Address - Street 1:1865 LYON AVE SW
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30331-8450
Mailing Address - Country:US
Mailing Address - Phone:404-272-1742
Mailing Address - Fax:404-344-6155
Practice Address - Street 1:4015 S COBB DR SE
Practice Address - Street 2:SUITE 220
Practice Address - City:SMYRNA
Practice Address - State:GA
Practice Address - Zip Code:30080-6303
Practice Address - Country:US
Practice Address - Phone:770-801-0980
Practice Address - Fax:770-801-9039
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-06
Last Update Date:2011-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA038930261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000625567JMedicaid
10171962OtherBIRTHDAY
UPIN 60764Medicare UPIN
GA000625567JMedicaid