Provider Demographics
NPI:1194787481
Name:EDEL, KENNETH PATRICK (MD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:PATRICK
Last Name:EDEL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:704-316-4979
Mailing Address - Fax:704-316-4978
Practice Address - Street 1:885 SUMMIT CROSSING PL
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-2193
Practice Address - Country:US
Practice Address - Phone:704-316-4979
Practice Address - Fax:704-316-4978
Is Sole Proprietor?:No
Enumeration Date:2006-04-04
Last Update Date:2024-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9800855207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8912123Medicaid
G42916Medicare UPIN
NC2059466Medicare PIN
NC2059466BMedicare PIN