Provider Demographics
NPI:1821385808
Name:KERNODLE CLINIC, INC-ELON
Entity Type:Organization
Organization Name:KERNODLE CLINIC, INC-ELON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:F
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
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:336-538-2390
Practice Address - Street 1:908 S WILLIAMSON AVE
Practice Address - Street 2:
Practice Address - City:ELON
Practice Address - State:NC
Practice Address - Zip Code:27244-9280
Practice Address - Country:US
Practice Address - Phone:336-538-2314
Practice Address - Fax:336-538-2390
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-29
Last Update Date:2013-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1569Medicare PIN