Provider Demographics
NPI:1528007176
Name:KIMMEL, BRIAN B (DO)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:B
Last Name:KIMMEL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4517 E THOMPSON ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19137-2003
Mailing Address - Country:US
Mailing Address - Phone:215-535-1275
Mailing Address - Fax:215-535-8690
Practice Address - Street 1:4517 E THOMPSON ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19137-2003
Practice Address - Country:US
Practice Address - Phone:215-535-1275
Practice Address - Fax:215-535-8690
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-06
Last Update Date:2013-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS005625L207Q00000X
PAOS-005625L311Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No311Z00000XNursing & Custodial Care FacilitiesCustodial Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0011449090003Medicaid
PA0011449090003Medicaid
PAB41380Medicare UPIN