=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316040926
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JIMMY CLARKE KIMBALL MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/07/2006
-----------------------------------------------------
Last Update Date | 10/13/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4600 ASHEVILLE HWY
-----------------------------------------------------
City | KNOXVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37914-3665
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 865-522-8114
-----------------------------------------------------
Fax | 866-550-6541
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 15004
-----------------------------------------------------
City | KNOXVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37901-5004
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 865-541-8895
-----------------------------------------------------
Fax | 865-633-4808
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | 13576
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------