Healthcare Provider Details

I. General information

NPI: 1942269204
Provider Name (Legal Business Name): KIMBERLY A BIRCH DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2006
Last Update Date: 04/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1108 CENTRAL AVENUE
MORIARTY NM
87035
US

IV. Provider business mailing address

12127B HWY 14 N STE 5
CEDAR CREST NM
87008-9461
US

V. Phone/Fax

Practice location:
  • Phone: 505-832-4434
  • Fax: 505-832-5024
Mailing address:
  • Phone: 505-832-4434
  • Fax: 505-832-5024

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036-115172
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA-1608-11
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: