1164460655 NPI number — DR. KIPP ALLEN VANCAMP DO

Table of content: DR. KIPP ALLEN VANCAMP DO (NPI 1164460655)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164460655 NPI number — DR. KIPP ALLEN VANCAMP DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VANCAMP
Provider First Name:
KIPP
Provider Middle Name:
ALLEN
Provider Name Prefix Text:
DR.
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:
1164460655
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/26/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3333 RIVERWOOD PKWY SE STE 250
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30339-3304
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-914-0116
Provider Business Mailing Address Fax Number:
770-955-4278

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
604 LOVEJOY LN STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WOODSTOCK
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30189-3634
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-268-4336
Provider Business Practice Location Address Fax Number:
470-251-6063
Provider Enumeration Date:
06/04/2006

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:  0525311 , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0202X , with the licence number: 103575 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 106163 . This is a "BCBS OF KS" identifier , issued by the state of ( KS ) . This identifiers is of the category "OTHER".
  • Identifier: 104991 . This is a "BCBS PROVIDER NUMBER" identifier , issued by the state of ( KS ) . This identifiers is of the category "OTHER".
  • Identifier: P00440177 . This is a "RAILROAD MEDICARE GROUP DG5299" identifier , issued by the state of ( KS ) . This identifiers is of the category "OTHER".
  • Identifier: 100234960F , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 18484065 . This is a "BCBS OF KANSAS CITY" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: P00477479 . This is a "RR MEDICARE" identifier , issued by the state of ( KS ) . This identifiers is of the category "OTHER".
  • Identifier: 1002234960H , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".
  • Identifier: KA1066001 . This is a "KS MEDICARE" identifier , issued by the state of ( KS ) . This identifiers is of the category "OTHER".




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