Healthcare Provider Details

I. General information

NPI: 1992942502
Provider Name (Legal Business Name): KIMBERLY GAIL KYKER MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/20/2009
Last Update Date: 02/22/2023
Certification Date: 02/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 HEALTHY WAY STE 1200
ANDERSON SC
29621-7916
US

IV. Provider business mailing address

PO BOX 100174
COLUMBIA SC
29202-3174
US

V. Phone/Fax

Practice location:
  • Phone: 864-512-6140
  • Fax: 864-512-6149
Mailing address:
  • Phone: 864-512-7257
  • Fax: 864-654-7672

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number31408
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number31408
License Number StateSC
# 3
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number31408
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: