Provider Demographics
NPI:1669574604
Name:KIMMERLE, GREGORY ROOK (MD)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:ROOK
Last Name:KIMMERLE
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:PO BOX 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7666 CHARLOTTE HWY
Practice Address - Street 2:STE 200
Practice Address - City:INDIAN LAND
Practice Address - State:SC
Practice Address - Zip Code:29707-7000
Practice Address - Country:US
Practice Address - Phone:803-431-8225
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2024-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2009-00969207R00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1669574604Medicaid
SC315616Medicaid
11SCFVVOtherUPIN-H25946
11SCFVVMedicare PIN
NC2075580Medicare PIN
NC1669574604Medicaid
SCAA48069246Medicare PIN