1578769428 NPI number — DR. JOHN KENNON KIRK M.D.

Table of content: DR. JOHN KENNON KIRK M.D. (NPI 1578769428)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578769428 NPI number — DR. JOHN KENNON KIRK M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KIRK
Provider First Name:
JOHN
Provider Middle Name:
KENNON
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1578769428
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/24/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
222 TONGASS DRIVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SITKA
Provider Business Mailing Address State Name:
AK
Provider Business Mailing Address Postal Code:
99835
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
907-966-8423
Provider Business Mailing Address Fax Number:
907-966-8606

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3245 HOSPITAL DRIVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JUNEAU
Provider Business Practice Location Address State Name:
AK
Provider Business Practice Location Address Postal Code:
99801
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
907-463-4040
Provider Business Practice Location Address Fax Number:
907-463-4075
Provider Enumeration Date:
06/26/2007

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:  TL-2561 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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