Provider Demographics
NPI:1972575074
Name:SWAIN DE POP, KIMBERELY K (MD)
Entity type:Individual
Prefix:
First Name:KIMBERELY
Middle Name:K
Last Name:SWAIN DE POP
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 1:8170 33RD AVE S # MS 21110Q
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55425-4516
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:451 DUNLAP ST N
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-4619
Practice Address - Country:US
Practice Address - Phone:651-647-2200
Practice Address - Fax:651-647-2075
Is Sole Proprietor?:No
Enumeration Date:2006-02-02
Last Update Date:2024-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN42159207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN327506000Medicaid
MN327506000Medicaid
110008142Medicare ID - Type Unspecified