Basic Information
| Provider Information | |||||||||
| NPI: | 1942269204 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BIRCH | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12127B HWY 14 N STE 5 | ||||||||
| Address2: | |||||||||
| City: | CEDAR CREST | ||||||||
| State: | NM | ||||||||
| PostalCode: | 870089461 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5058324434 | ||||||||
| FaxNumber: | 5058325024 | ||||||||
| Practice Location | |||||||||
| Address1: | 1108 CENTRAL AVENUE | ||||||||
| Address2: | |||||||||
| City: | MORIARTY | ||||||||
| State: | NM | ||||||||
| PostalCode: | 87035 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5058324434 | ||||||||
| FaxNumber: | 5058325024 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/23/2006 | ||||||||
| LastUpdateDate: | 04/05/2012 | ||||||||
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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 | 207R00000X | 036-115172 | IL | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | A-1608-11 | NM | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 036115172 | 05 | IL | MEDICAID |