Basic Information
| Provider Information | |||||||||
| NPI: | 1528035268 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KINDLE-SUERSIN | ||||||||
| FirstName: | KESI | ||||||||
| MiddleName: | TABIA | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KINDLE | ||||||||
| OtherFirstName: | KESI | ||||||||
| OtherMiddleName: | TABIA | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3333 SILAS CREEK PKWY | ||||||||
| Address2: | |||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271033013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367187041 | ||||||||
| FaxNumber: | 3367189622 | ||||||||
| Practice Location | |||||||||
| Address1: | 3333 SILAS CREEK PKWY | ||||||||
| Address2: | |||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271033013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367168386 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/01/2006 | ||||||||
| LastUpdateDate: | 09/11/2009 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0300X | 200200933 | NC | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3810000708 | 05 | WV | MEDICAID | D6480 | 01 | MEDCOST | OTHER | Q00933 | 05 | SC | MEDICAID | 13153 | 01 | NC | BCBS | OTHER | 7706384 | 01 | AETNA | OTHER | 804752 | 01 | PARTNERS | OTHER | 8913153 | 05 | NC | MEDICAID | 10100496 | 05 | VA | MEDICAID | H64259 | 01 | NC | UHC | OTHER |