Provider Demographics
NPI:1134120595
Name:KIMMEL, STEPHEN W (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:W
Last Name:KIMMEL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:360 SUNSET AVE
Mailing Address - Street 2:
Mailing Address - City:ASHEBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27203-5612
Mailing Address - Country:US
Mailing Address - Phone:336-625-8410
Mailing Address - Fax:336-625-8405
Practice Address - Street 1:360 SUNSET AVE
Practice Address - Street 2:
Practice Address - City:ASHEBORO
Practice Address - State:NC
Practice Address - Zip Code:27203-5612
Practice Address - Country:US
Practice Address - Phone:336-625-8410
Practice Address - Fax:336-625-8405
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9600812207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8950271Medicaid
NCG37685Medicare UPIN
NC2232579EMedicare ID - Type Unspecified