Provider Demographics
NPI:1871738583
Name:ANDERSON, KIMBERLAND SHARESH (MD)
Entity type:Individual
Prefix:
First Name:KIMBERLAND
Middle Name:SHARESH
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KIMBERLAND
Other - Middle Name:SHARESH
Other - Last Name:THOMPSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 781076
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-1076
Mailing Address - Country:US
Mailing Address - Phone:317-528-4800
Mailing Address - Fax:317-865-1479
Practice Address - Street 1:7905 CALUMET AVE
Practice Address - Street 2:
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321-2549
Practice Address - Country:US
Practice Address - Phone:219-836-3049
Practice Address - Fax:219-836-7295
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-09
Last Update Date:2023-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036123265207Q00000X
IN01073217A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL834340OtherMEDICARE GROUP PTAN
IN201193760Medicaid
IL553180OtherMEDICARE GROUP PTAN
IL553180033Medicare PIN
IL553180OtherMEDICARE GROUP PTAN
IN266180290Medicare PIN