Basic Information
| Provider Information | |||||||||
| NPI: | 1275560773 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FREESE-BEAL | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | SUE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | FRESSE | ||||||||
| OtherFirstName: | KIMBERLY | ||||||||
| OtherMiddleName: | SUE | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 67000 | ||||||||
| Address2: | DEPARTMENT 272801 | ||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482672728 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5177840141 | ||||||||
| FaxNumber: | 5177873462 | ||||||||
| Practice Location | |||||||||
| Address1: | 400 HINCKLEY BLVD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | JACKSON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 492036125 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5177840141 | ||||||||
| FaxNumber: | 5177873462 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2006 | ||||||||
| LastUpdateDate: | 02/16/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 4301082465 | MI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.