Provider Demographics
NPI:1962678771
Name:GARY KIMMEL MD PC
Entity Type:Organization
Organization Name:GARY KIMMEL MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:KIMMEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-832-9488
Mailing Address - Street 1:112 PROSPECT PARK W
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11215-3710
Mailing Address - Country:US
Mailing Address - Phone:718-832-9488
Mailing Address - Fax:718-369-1753
Practice Address - Street 1:112 PROSPECT PARK W
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11215-3710
Practice Address - Country:US
Practice Address - Phone:718-832-9488
Practice Address - Fax:718-369-1753
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-01
Last Update Date:2008-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY214093208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02310525Medicaid
NY02310525Medicaid