Healthcare Provider Details

I. General information

NPI: 1053576496
Provider Name (Legal Business Name): SAMUEL W KIMANI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2008
Last Update Date: 03/24/2023
Certification Date: 03/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 S LANDMARK AVE
BLOOMINGTON IN
47403
US

IV. Provider business mailing address

3943 E FENBROOK LN
BLOOMINGTON IN
47401-7739
US

V. Phone/Fax

Practice location:
  • Phone: 812-331-3400
  • Fax: 812-332-7265
Mailing address:
  • Phone: 812-345-8890
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2014-02169
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number2014-02169
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number2014-02169
License Number StateNC
# 4
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number01081868A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: