Provider Demographics
NPI:1992781462
Name:MCKIBBEN, JULIE MARIE (MD)
Entity type:Individual
Prefix:
First Name:JULIE
Middle Name:MARIE
Last Name:MCKIBBEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JULIE
Other - Middle Name:MARIE
Other - Last Name:BOLENBAUGH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4810 WHITESPORT CIR SW
Mailing Address - Street 2:SUITE 215
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35801-7419
Mailing Address - Country:US
Mailing Address - Phone:256-429-4540
Mailing Address - Fax:256-429-4546
Practice Address - Street 1:4810 WHITESPORT CIR SW
Practice Address - Street 2:SUITE 215
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35801-7419
Practice Address - Country:US
Practice Address - Phone:256-429-4540
Practice Address - Fax:256-429-4546
Is Sole Proprietor?:No
Enumeration Date:2005-12-16
Last Update Date:2013-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC26530208D00000X
ALMD 298392083X0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
000OTHMedicare UPIN
AL102I849527Medicare PIN