MEDICARE: KIMBERLY C MAYROSE M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P0800X	Psychiatry Physician	01054989	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1073567616
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KIMBERLY C MAYROSE M.D.

Provider Business Mailing Address
First Line	:	2705 N LEBANON ST STE 305
Second Line	:
City	:	LEBANON
State	:	IN
Zip	:	46052-8622
Country	:	US
Telephone Number	:	765-485-8852
Fax Number	:	765-485-8669

Provider Business Practice Location Address
First Line	:	1650 W OAK ST STE 200
Second Line	:
City	:	ZIONSVILLE
State	:	IN
Zip	:	46077-3836
Country	:	US
Telephone Number	:	317-912-1399
Fax Number	:	765-680-0468

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/19/2006
Last Update Date	:	07/21/2022

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