Basic Information
| Provider Information | |||||||||
| NPI: | 1871587709 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GAUTHIER | ||||||||
| FirstName: | KIMBER | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 22487 | ||||||||
| Address2: | |||||||||
| City: | GREEN BAY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 543052487 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9204457210 | ||||||||
| FaxNumber: | 9204457289 | ||||||||
| Practice Location | |||||||||
| Address1: | 610 S LINCOLN RD | ||||||||
| Address2: | |||||||||
| City: | ESCANABA | ||||||||
| State: | MI | ||||||||
| PostalCode: | 498291215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9067866488 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/07/2005 | ||||||||
| LastUpdateDate: | 07/26/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/26/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 4301082649 | MI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | P00064002 | 01 | MI | RAILROAD MEDICARE | OTHER | 4545812 | 05 | MI | MEDICAID | KG082649 | 01 | MI | BCBS OF MICHIGAN | OTHER |