Healthcare Provider Details

I. General information

NPI: 1841380235
Provider Name (Legal Business Name): RUSSELL B KIMBALL PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 ARSENAL ST
AUGUSTA ME
04333-0011
US

IV. Provider business mailing address

31 JOHNSON STREET
SOUTH GARDINER ME
04359
US

V. Phone/Fax

Practice location:
  • Phone: 207-624-4657
  • Fax: 207-287-6123
Mailing address:
  • Phone: 207-512-2318
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA590
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: