Basic Information
| Provider Information | |||||||||
| NPI: | 1962455592 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RUSSELL | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 901 E. 104TH ST. | ||||||||
| Address2: | MAILSTOP 400N | ||||||||
| City: | KANSAS CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 641314517 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8165027104 | ||||||||
| FaxNumber: | 8169329670 | ||||||||
| Practice Location | |||||||||
| Address1: | 12541 FOSTER ST | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | OVERLAND PARK | ||||||||
| State: | KS | ||||||||
| PostalCode: | 662132630 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9133173200 | ||||||||
| FaxNumber: | 9133173218 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2006 | ||||||||
| LastUpdateDate: | 02/27/2018 | ||||||||
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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 | 207Q00000X | 0428043 | KS | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 100339820C | 05 | KS | MEDICAID |