Healthcare Provider Details

I. General information

NPI: 1164714556
Provider Name (Legal Business Name): KIMBERLY SUE VAN ELK M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/04/2011
Last Update Date: 04/26/2021
Certification Date: 04/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 HIGH PARK AVE
GOSHEN IN
46526-4810
US

IV. Provider business mailing address

7520 TOSCANA CT
GRANGER IN
46530-8056
US

V. Phone/Fax

Practice location:
  • Phone: 574-364-1000
  • Fax:
Mailing address:
  • Phone: 765-748-2309
  • Fax: 574-233-3125

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number01073789
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: