Provider Demographics
NPI:1366425316
Name:MUDGE, KIMBERLEE (MD)
Entity type:Individual
Prefix:
First Name:KIMBERLEE
Middle Name:
Last Name:MUDGE
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 1:409 S 2ND ST STE 2F
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17104-1612
Mailing Address - Country:US
Mailing Address - Phone:717-741-3449
Mailing Address - Fax:717-741-5496
Practice Address - Street 1:1703 INNOVATION DRIVE
Practice Address - Street 2:SUITE 3136
Practice Address - City:YORK
Practice Address - State:PA
Practice Address - Zip Code:17408-8815
Practice Address - Country:US
Practice Address - Phone:717-741-3449
Practice Address - Fax:717-741-5496
Is Sole Proprietor?:No
Enumeration Date:2005-11-23
Last Update Date:2021-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD053182L208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1597216Medicaid
PA1597216Medicaid
PA888939Medicare ID - Type Unspecified