Basic Information
Provider Information
NPI: 1003806514
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: KIMBALL
FirstName: RONALD
MiddleName: E
NamePrefix: DR.
NameSuffix:  
Credential: MD
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 611 W. PARK ST.
Address2: BWPC
City: URBANA
State: IL
PostalCode: 618012500
CountryCode: US
TelephoneNumber: 2173836792
FaxNumber:  
Practice Location
Address1: 509 W UNIVERSITY AVE
Address2:  
City: URBANA
State: IL
PostalCode: 618011645
CountryCode: US
TelephoneNumber: 2173836636
FaxNumber: 2173833466
Other Information
ProviderEnumerationDate: 10/26/2005
LastUpdateDate: 05/26/2015
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207VX0201X036128873ILY Allopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologic Oncology
207VX0201X45330CON Allopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologic Oncology

ID Information
IDTypeStateIssuerDescription
01806101COKAISER COMMERCIAL NUMBEROTHER
5257273105CO MEDICAID


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