Provider Demographics
NPI:1881656502
Name:GIMBEL, KENNETH S (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:S
Last Name:GIMBEL
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 1:6507 PROFESSIONAL PL
Mailing Address - Street 2:
Mailing Address - City:RIVERDALE
Mailing Address - State:GA
Mailing Address - Zip Code:30274-4941
Mailing Address - Country:US
Mailing Address - Phone:770-991-2100
Mailing Address - Fax:770-991-1180
Practice Address - Street 1:6507 PROFESSIONAL PL
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:GA
Practice Address - Zip Code:30274-4941
Practice Address - Country:US
Practice Address - Phone:770-991-2100
Practice Address - Fax:770-991-1180
Is Sole Proprietor?:No
Enumeration Date:2006-04-06
Last Update Date:2008-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA018653207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAD29563Medicare UPIN
11BDPNZMedicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER