1336208552 NPI number — MICHAEL S. KIRK, JR.

Table of content: (NPI 1336208552)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336208552 NPI number — MICHAEL S. KIRK, JR.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MICHAEL S. KIRK, JR.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
PERFORMANCE HEALTH & CHIROPRACTIC
Provider Other Organization Name Type Code:
3
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:
1336208552
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/23/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
300 CHESTER AVE
Provider Second Line Business Mailing Address:
SUITE 102
Provider Business Mailing Address City Name:
MOORESTOWN
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08057-2512
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
856-727-8300
Provider Business Mailing Address Fax Number:
856-727-8346

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
300 CHESTER AVE
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
MOORESTOWN
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08057-2512
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
856-727-8300
Provider Business Practice Location Address Fax Number:
856-727-8346
Provider Enumeration Date:
12/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KIRK
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
S.
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
856-727-8300

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  38MC00578200 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 3557463 . This is a "AETNA" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 7272582 . This is a "AETNA" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 2410673000 . This is a "AMERIHEALTH IBC" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 001745107 . This is a "PERSONAL CHOICE" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".




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