Provider Demographics
NPI:1689611022
Name:KERNODLE CLINIC, INC
Entity Type:Organization
Organization Name:KERNODLE CLINIC, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:A
Authorized Official - Last Name:BILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-538-1234
Mailing Address - Street 1:PO BOX 1717
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27216-1717
Mailing Address - Country:US
Mailing Address - Phone:336-538-1234
Mailing Address - Fax:336-584-6811
Practice Address - Street 1:1234 HUFFMAN MILL RD
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:NC
Practice Address - Zip Code:27215-8700
Practice Address - Country:US
Practice Address - Phone:336-538-1234
Practice Address - Fax:336-584-6811
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-02
Last Update Date:2012-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1569Medicare PIN
NC0354770001Medicare NSC