Provider Demographics
NPI:1093700338
Name:ELK RIVER MEDICAL ASSOCIATES, PA
Entity Type:Organization
Organization Name:ELK RIVER MEDICAL ASSOCIATES, PA
Other - Org Name:ELK RIVER INTERNAL MEDICINE
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT/STAFF PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:KIMMEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:828-898-5177
Mailing Address - Street 1:PO BOX 1568
Mailing Address - Street 2:
Mailing Address - City:BANNER ELK
Mailing Address - State:NC
Mailing Address - Zip Code:28604-1568
Mailing Address - Country:US
Mailing Address - Phone:828-898-5177
Mailing Address - Fax:828-898-8306
Practice Address - Street 1:150 PARK AVE
Practice Address - Street 2:
Practice Address - City:BANNER ELK
Practice Address - State:NC
Practice Address - Zip Code:28604-6604
Practice Address - Country:US
Practice Address - Phone:828-898-5177
Practice Address - Fax:828-898-8306
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC38891261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC890150BMedicaid
NCC14617OtherGROUP RAILROAD MEDICARE
NC0150BOtherNC BLUECROSS BLUESHIELD
TN4404134Medicaid
TN112304OtherTN BLUECROSS&TENNCARE
NC2310477Medicare ID - Type UnspecifiedGROUP NC MEDICARE NUMBER
NC890150BMedicaid