=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194785899
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EDWARD A KEPP MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/25/2006
-----------------------------------------------------
Last Update Date | 03/17/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 232 CONCORD RD
-----------------------------------------------------
City | ALBEMARLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28001-4612
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-986-3900
-----------------------------------------------------
Fax | 704-986-3913
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 232 CONCORD RD
-----------------------------------------------------
City | ALBEMARLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28001-4612
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-986-3900
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 94-00873
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 9400873
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------