Provider Demographics
NPI:1700892148
Name:KIMMEL, STEPHEN G (MD)
Entity type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:G
Last Name:KIMMEL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:NEMOURS CHILDREN&APOS S CLINIC
Mailing Address - Street 2:P.O. BOX 409992
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-0001
Mailing Address - Country:US
Mailing Address - Phone:904-390-3610
Mailing Address - Fax:904-288-5890
Practice Address - Street 1:450 W MEDICAL CENTER BLVD
Practice Address - Street 2:SUITE 600C
Practice Address - City:WEBSTER
Practice Address - State:TX
Practice Address - Zip Code:77598-4234
Practice Address - Country:US
Practice Address - Phone:281-554-1690
Practice Address - Fax:281-316-0590
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2022-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME909822086S0120X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL270540100Medicaid
AL009964275Medicaid
MS09680055Medicaid
AL009964275Medicaid
I16025Medicare UPIN