Provider Demographics
NPI:1538231154
Name:GINEVAN, KIM B (MD)
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:B
Last Name:GINEVAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KIM
Other - Middle Name:
Other - Last Name:BECHARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:324 GANNETT DR STE 200
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-3266
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:324 GANNETT DR STE 200
Practice Address - Street 2:
Practice Address - City:SOUTH PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04106-3266
Practice Address - Country:US
Practice Address - Phone:207-662-2959
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2015-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMD16619207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME023219OtherANTHEM
ME7110395OtherAETNA
ME416990099Medicaid
MEH74980Medicare UPIN
MEP00157164Medicare ID - Type UnspecifiedRAILROAD
MEH74980OtherHPHC
ME3629458OtherAETNA USHC
MEM108785OtherCIGNA
MEME0921Medicare ID - Type Unspecified