1093700338 NPI number — ELK RIVER MEDICAL ASSOCIATES, PA

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093700338 NPI number — ELK RIVER MEDICAL ASSOCIATES, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ELK RIVER MEDICAL ASSOCIATES, PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
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:
1093700338
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1568
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BANNER ELK
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28604-1568
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
828-898-5177
Provider Business Mailing Address Fax Number:
828-898-8306

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
150 PARK AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BANNER ELK
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28604-6604
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
828-898-5177
Provider Business Practice Location Address Fax Number:
828-898-8306
Provider Enumeration Date:
09/13/2005

Additional Information

Authorized Official

Authorized Official Last Name:
KIMMEL
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
PAUL
Authorized Official Title or Position:
PRESIDENT/STAFF PHYSICIAN
Authorized Official Telephone Number:
828-898-5177

Provider Taxonomy Codes

  • Taxonomy code: 261QM1300X , with the licence number:  38891 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 890150B , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: C14617 . This is a "GROUP RAILROAD MEDICARE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 0150B . This is a "NC BLUECROSS BLUESHIELD" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 4404134 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 112304 . This is a "TN BLUECROSS&TENNCARE" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".




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