Healthcare Provider Details

I. General information

NPI: 1366677676
Provider Name (Legal Business Name): KIMBERLY M KILGORE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2009
Last Update Date: 07/13/2020
Certification Date: 07/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3600 FOREST DR STE 300
COLUMBIA SC
29204-4057
US

IV. Provider business mailing address

PO BOX 743904
ATLANTA GA
30374-3904
US

V. Phone/Fax

Practice location:
  • Phone: 803-749-5101
  • Fax: 803-933-3045
Mailing address:
  • Phone: 803-296-7320
  • Fax: 803-296-7330

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number26381
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number61239
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: