Provider Demographics
NPI:1992821482
Name:SANDY J. KIMMEL, D.O., P.A.
Entity type:Organization
Organization Name:SANDY J. KIMMEL, D.O., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:BONNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:DONLEYCOTT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-872-0390
Mailing Address - Street 1:3400 EXECUTIVE DR
Mailing Address - Street 2:SUITE 203
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27609-7476
Mailing Address - Country:US
Mailing Address - Phone:919-872-0390
Mailing Address - Fax:919-872-0391
Practice Address - Street 1:3400 EXECUTIVE DR
Practice Address - Street 2:SUITE 203
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-7476
Practice Address - Country:US
Practice Address - Phone:919-872-0390
Practice Address - Fax:919-872-0391
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SANDY J. KIMMEL, D.O, P.A.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-03-22
Last Update Date:2011-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200400893174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89137PCMedicaid
NC1598714313OtherINDIVIDUAL NPI NUMBER
NC1598714313OtherINDIVIDUAL NPI NUMBER
NC2402208Medicare ID - Type UnspecifiedMEDICARE PROVIDER NO.