1891780631 NPI number — DOUGLAS KIMMEL D.O.

Table of content: DOUGLAS KIMMEL D.O. (NPI 1891780631)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891780631 NPI number — DOUGLAS KIMMEL D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KIMMEL
Provider First Name:
DOUGLAS
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
D.O.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1891780631
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/02/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1648 HUNTINGDON PIKE
Provider Second Line Business Mailing Address:
MEDICAL STAFF OFFICE 1ST FLR
Provider Business Mailing Address City Name:
MEADOWBROOK
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19046-8001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
215-938-3450
Provider Business Mailing Address Fax Number:
215-938-3829

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
23 BUSTLETON PIKE
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
FEASTERVILLE TREVOSE
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19053-6446
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-464-9599
Provider Business Practice Location Address Fax Number:
215-464-7865
Provider Enumeration Date:
09/19/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  OS006506L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 570038 . This is a "PA BLUE SHIELD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 01767OS006506L , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0391404000 . This is a "KEYSTONE HEALTH PLAN EAST" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 98765 . This is a "AETNA US HEATLHCARE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 100416C , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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