Basic Information
| Provider Information | |||||||||
| NPI: | 1255307591 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KIMMEL | ||||||||
| FirstName: | CRAIG | ||||||||
| MiddleName: | S. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 500 GROVE ST | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | HADDON HEIGHTS | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080351761 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8567969200 | ||||||||
| FaxNumber: | 8567969397 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 BRACE ROAD | ||||||||
| Address2: | SUITE B | ||||||||
| City: | CHERRY HILL | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 08034 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8564709029 | ||||||||
| FaxNumber: | 8564284053 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/27/2006 | ||||||||
| LastUpdateDate: | 06/25/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QS0010X | 25MA05473800 | NJ | Y | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2223902 | 05 | NJ | MEDICAID |