Basic Information
| Provider Information | |||||||||
| NPI: | 1518900950 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRANDT | ||||||||
| FirstName: | KIM | ||||||||
| MiddleName: | B. | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5101 BRENNER RD NW | ||||||||
| Address2: | |||||||||
| City: | OLYMPIA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985021534 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3193298908 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3900 CAPITOL MALL DR SW | ||||||||
| Address2: | |||||||||
| City: | OLYMPIA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985028654 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3607545858 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2006 | ||||||||
| LastUpdateDate: | 08/24/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 20279 | IA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | MD00045715 | WA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207P00000X | MD00045715 | WA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1012308 | 05 | WA | MEDICAID | 3076BR | 01 | WA | BSWA | OTHER | 8444226 | 05 | WA | MEDICAID | 0236140 | 01 | WA | LIWA VCR | OTHER | P00626487 | 01 | WA | RRGA | OTHER |