Provider Demographics
NPI:1356315543
Name:KIMBLE, GREGORY ALLEN (DO)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:ALLEN
Last Name:KIMBLE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:227 HOSPITAL DR
Mailing Address - Street 2:SUITE 1
Mailing Address - City:EVERETT
Mailing Address - State:PA
Mailing Address - Zip Code:15537-7019
Mailing Address - Country:US
Mailing Address - Phone:814-623-9095
Mailing Address - Fax:
Practice Address - Street 1:227 HOSPITAL DR
Practice Address - Street 2:SUITE 1
Practice Address - City:EVERETT
Practice Address - State:PA
Practice Address - Zip Code:15537-7019
Practice Address - Country:US
Practice Address - Phone:814-623-9095
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-14
Last Update Date:2020-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS006868L174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001167574Medicaid
PA580405PEEMedicare ID - Type Unspecified