Basic Information
| Provider Information | |||||||||
| NPI: | 1871593244 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PANZARELLA | ||||||||
| FirstName: | KIM | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 201 CONCOURSE BLVD STE 200 | ||||||||
| Address2: | |||||||||
| City: | GLEN ALLEN | ||||||||
| State: | VA | ||||||||
| PostalCode: | 230595640 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8045494030 | ||||||||
| FaxNumber: | 8045494032 | ||||||||
| Practice Location | |||||||||
| Address1: | 320A CHARLES H DIMMOCK PKWY | ||||||||
| Address2: | |||||||||
| City: | COLONIAL HEIGHTS | ||||||||
| State: | VA | ||||||||
| PostalCode: | 238342917 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8045267364 | ||||||||
| FaxNumber: | 8045267394 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2005 | ||||||||
| LastUpdateDate: | 07/05/2019 | ||||||||
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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 | 207N00000X | 0101231763 | VA | Y | Allopathic & Osteopathic Physicians | Dermatology |
ID Information
| ID | Type | State | Issuer | Description | 2906423 | 01 | AETNA | OTHER | 070016578 | 01 | RAILROAD MEDICARE | OTHER | 005902096 | 05 | VA | MEDICAID | 0300462 | 01 | UNITED HEALTHCARE | OTHER | 150946 | 01 | SOUTHERN HEALTH | OTHER | 384358 | 01 | ANTHEM | OTHER |