1730130253 NPI number — SUMMER J KIMBLE PA-C

Table of content: SUMMER J KIMBLE PA-C (NPI 1730130253)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730130253 NPI number — SUMMER J KIMBLE PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KIMBLE
Provider First Name:
SUMMER
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

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:
1730130253
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/11/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
150 S SUNNY SLOPE RD
Provider Second Line Business Mailing Address:
SUITE 136
Provider Business Mailing Address City Name:
BROOKFIELD
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53005-6461
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
262-786-4550
Provider Business Mailing Address Fax Number:
262-786-4552

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
150 S SUNNY SLOPE RD
Provider Second Line Business Practice Location Address:
SUITE 136
Provider Business Practice Location Address City Name:
BROOKFIELD
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53005-6461
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
262-786-4550
Provider Business Practice Location Address Fax Number:
262-786-4552
Provider Enumeration Date:
05/12/2006

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: 363A00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1730130253 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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