Basic Information
Provider Information | |||||||||
NPI: | 1689671406 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CROSS | ||||||||
FirstName: | KIMBERLY | ||||||||
MiddleName: | SUE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 800 PENNSYLVANIA AVE | ||||||||
Address2: | CHILDREN'S MEDICINE CENTER | ||||||||
City: | CHARLESTON | ||||||||
State: | WV | ||||||||
PostalCode: | 25302 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3043882525 | ||||||||
FaxNumber: | 3043882537 | ||||||||
Practice Location | |||||||||
Address1: | 800 PENNSYLVANIA AVE | ||||||||
Address2: |   | ||||||||
City: | CHARLESTON | ||||||||
State: | WV | ||||||||
PostalCode: | 253023351 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3043882526 | ||||||||
FaxNumber: | 3043882537 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/07/2005 | ||||||||
LastUpdateDate: | 07/05/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 19689 | WV | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 208000000X | 19689 | WV | Y |   | Allopathic & Osteopathic Physicians | Pediatrics |   |
ID Information
ID | Type | State | Issuer | Description | 7354454 | 01 | WV | AETNA | OTHER | 3002030000 | 05 | WV |   | MEDICAID | 001721334 | 01 | WV | MS BCBS | OTHER |