1164714556 NPI number — DR. KIMBERLY SUE VAN ELK M.D.

Table of content: DR. KIMBERLY SUE VAN ELK M.D. (NPI 1164714556)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164714556 NPI number — DR. KIMBERLY SUE VAN ELK M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VAN ELK
Provider First Name:
KIMBERLY
Provider Middle Name:
SUE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1164714556
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/26/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7520 TOSCANA CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRANGER
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46530-8056
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
765-748-2309
Provider Business Mailing Address Fax Number:
574-233-3125

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
200 HIGH PARK AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GOSHEN
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46526-4810
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
574-364-1000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/04/2011

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: 207L00000X , with the licence number:  01073789 , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 201110000 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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