Basic Information
| Provider Information | |||||||||
| NPI: | 1548437718 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KIMBALL | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | D. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2151 OLD ROCKY RIDGE RD | ||||||||
| Address2: | SUITE 106 | ||||||||
| City: | BIRMINGHAM | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352167235 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2059891080 | ||||||||
| FaxNumber: | 2059891087 | ||||||||
| Practice Location | |||||||||
| Address1: | 315 W HICKORY ST | ||||||||
| Address2: | |||||||||
| City: | SYLACAUGA | ||||||||
| State: | AL | ||||||||
| PostalCode: | 351502913 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2564014605 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2008 | ||||||||
| LastUpdateDate: | 06/05/2019 | ||||||||
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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 | 207L00000X | MD.31741 | AL | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 06037 | 05 | LA | MEDICAID |