Healthcare Provider Details

I. General information

NPI: 1255353603
Provider Name (Legal Business Name): KIMBERLY P. MARSHALL M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1302 FRANKLIN AVE STE 2500
NORMAL IL
61761-6526
US

IV. Provider business mailing address

PO BOX 2451
BLOOMINGTON IL
61702-2451
US

V. Phone/Fax

Practice location:
  • Phone: 309-268-2727
  • Fax: 309-268-6513
Mailing address:
  • Phone: 309-268-2172
  • Fax: 309-268-3649

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number StateIL

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier5723019
Identifier TypeOTHER
Identifier State
Identifier IssuerBLUE CROSS BLUE SHIELD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: