Healthcare Provider Details

I. General information

NPI: 1003806514
Provider Name (Legal Business Name): RONALD E KIMBALL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2005
Last Update Date: 05/26/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

509 W UNIVERSITY AVE
URBANA IL
61801-1645
US

IV. Provider business mailing address

611 W. PARK ST. BWPC
URBANA IL
61801-2500
US

V. Phone/Fax

Practice location:
  • Phone: 217-383-6636
  • Fax: 217-383-3466
Mailing address:
  • Phone: 217-383-6792
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207VX0201X
TaxonomyGynecologic Oncology Physician
License Number45330
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code207VX0201X
TaxonomyGynecologic Oncology Physician
License Number036128873
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: