Provider Demographics
NPI:1871587709
Name:GAUTHIER, KIMBER M (MD)
Entity type:Individual
Prefix:MS
First Name:KIMBER
Middle Name:M
Last Name:GAUTHIER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 22487
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54305-2487
Mailing Address - Country:US
Mailing Address - Phone:920-445-7210
Mailing Address - Fax:920-445-7289
Practice Address - Street 1:610 S LINCOLN RD
Practice Address - Street 2:
Practice Address - City:ESCANABA
Practice Address - State:MI
Practice Address - Zip Code:49829-1215
Practice Address - Country:US
Practice Address - Phone:906-786-6488
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-07
Last Update Date:2022-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301082649207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP00064002OtherRAILROAD MEDICARE
MI4545812Medicaid
MIKG082649OtherBCBS OF MICHIGAN
MIP00878155Medicare Oscar/Certification
MIP38340019Medicare Oscar/Certification
H41146Medicare UPIN