1720042674 NPI number — JOEL P KIMELMAN DO

Table of content: JOEL P KIMELMAN DO (NPI 1720042674)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720042674 NPI number — JOEL P KIMELMAN DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KIMELMAN
Provider First Name:
JOEL
Provider Middle Name:
P
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
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:
1720042674
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/23/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3346 LENNON ROAD
Provider Second Line Business Mailing Address:
SUITE 2
Provider Business Mailing Address City Name:
FLINT
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48507-1015
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
810-732-1919
Provider Business Mailing Address Fax Number:
810-732-3740

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3346 LENNON ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FLINT
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48507-1015
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
810-732-1919
Provider Business Practice Location Address Fax Number:
810-732-3740
Provider Enumeration Date:
04/15/2006

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: 2085R0202X , with the licence number:  JK005903 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0202X , with the licence number: 5101005903 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 4398860 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4477536 . This is a "AETNA" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 57100 . This is a "OMNICARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 016618 . This is a "MIDWEST HEALTH PLANS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 136504 . This is a "GREAT LAKES HEALTH PLAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 300Q264480 . This is a "BCBSM/BCN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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