Basic Information
Provider Information | |||||||||
NPI: | 1346299559 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KIMM | ||||||||
FirstName: | G | ||||||||
MiddleName: | EDWARD | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: | JR. | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 500 ELDORADO BLVD # 6250 | ||||||||
Address2: |   | ||||||||
City: | BROOMFIELD | ||||||||
State: | CO | ||||||||
PostalCode: | 800213408 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3032720751 | ||||||||
FaxNumber: | 3033182488 | ||||||||
Practice Location | |||||||||
Address1: | 1960 OGDEN ST STE 400 | ||||||||
Address2: |   | ||||||||
City: | DENVER | ||||||||
State: | CO | ||||||||
PostalCode: | 802183670 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3033181540 | ||||||||
FaxNumber: | 3033183825 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/08/2006 | ||||||||
LastUpdateDate: | 01/03/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 31626 | CO | Y |   | Allopathic & Osteopathic Physicians | Surgery |   |
ID Information
ID | Type | State | Issuer | Description | 01316264 | 05 | CO |   | MEDICAID |