1073553251 NPI number — MICHAEL D KIRK MD

Table of content: MICHAEL D KIRK MD (NPI 1073553251)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073553251 NPI number — MICHAEL D KIRK MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KIRK
Provider First Name:
MICHAEL
Provider Middle Name:
D
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1073553251
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/13/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
455 WOODVIEW RD STE 100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WEST GROVE
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19390-9314
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
610-345-1900
Provider Business Mailing Address Fax Number:
610-345-1901

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
455 WOODVIEW RD STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WEST GROVE
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19390-9314
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
610-345-1900
Provider Business Practice Location Address Fax Number:
610-345-1901
Provider Enumeration Date:
06/07/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  MD044838E , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 080040186 . This is a "RR MEDICARE" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 0053361000 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5304114 . This is a "AETNA" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 000610071 . This is a "MS BCBS" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".