Basic Information
| Provider Information | |||||||||
| NPI: | 1336302454 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SPAN | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | M. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1060 FIRST COLONIAL RD | ||||||||
| Address2: | |||||||||
| City: | VIRGINIA BEACH | ||||||||
| State: | VA | ||||||||
| PostalCode: | 234543002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7573952323 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 825 FAIRFAX AVE | ||||||||
| Address2: | SUITE 445 | ||||||||
| City: | NORFOLK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 235071914 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7574468920 | ||||||||
| FaxNumber: | 7574465242 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/09/2008 | ||||||||
| LastUpdateDate: | 10/16/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | 0101246307 | VA | N | Allopathic & Osteopathic Physicians | Hospitalist | 207R00000X | 0101246307 | VA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | PAR | 01 | VA | VIRGINIA PREMIER HEALTH PLAN | OTHER | PAR | 01 | VA | AETNA | OTHER | -028 | 01 | VA | TRICARE/CHAMPUS | OTHER | 1336302454 | 01 | VA | FIRST HEALTH NETWORK/COVENTRY HEALTH | OTHER | PAR | 01 | VA | USA MANAGED CARE | OTHER | PAR | 01 | VA | CIGNA | OTHER | PAR | 01 | VA | MULTIPLAN | OTHER | 10071693 | 01 | VA | SENTARA/OPTIMA HEALTH | OTHER | 1336302454 | 05 | VA | MEDICAID | 422982 | 01 | VA | ANTHEM BC/BS | OTHER | PAR | 01 | VA | CORVEL/CORCARE | OTHER | PAR | 01 | VA | UNITED HEALTHCARE | OTHER | 5916953 | 05 | NC | MEDICAID | PAR | 01 | VA | VIRGINIA HEALTH NETWORK | OTHER |