Basic Information
| Provider Information | |||||||||
| NPI: | 1124169453 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KIMBALL | ||||||||
| FirstName: | SEAN | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 PARK STREET | ||||||||
| Address2: | GLENS FALLS HOSPITAL - CREDENTIALING | ||||||||
| City: | GLENS FALLS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 128014413 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5189265924 | ||||||||
| FaxNumber: | 5189266983 | ||||||||
| Practice Location | |||||||||
| Address1: | 79 NORTH ST | ||||||||
| Address2: | GRANVILLE FAMILY HEALTH | ||||||||
| City: | GRANVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 128321137 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5186420612 | ||||||||
| FaxNumber: | 5186420693 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/09/2007 | ||||||||
| LastUpdateDate: | 09/26/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 249528 | NY | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | P00642757 | 01 | NY | RR MEDICARE | OTHER | 03028888 | 05 | NY | MEDICAID |