Healthcare Provider Details

I. General information

NPI: 1093700338
Provider Name (Legal Business Name): ELK RIVER MEDICAL ASSOCIATES, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/13/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 PARK AVE
BANNER ELK NC
28604-6604
US

IV. Provider business mailing address

PO BOX 1568
BANNER ELK NC
28604-1568
US

V. Phone/Fax

Practice location:
  • Phone: 828-898-5177
  • Fax: 828-898-8306
Mailing address:
  • Phone: 828-898-5177
  • Fax: 828-898-8306

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number38891
License Number StateNC

VIII. Authorized Official

Name: DR. DAVID PAUL KIMMEL
Title or Position: PRESIDENT/STAFF PHYSICIAN
Credential: MD
Phone: 828-898-5177