Provider Demographics
NPI:1083891600
Name:TODD S. KIRK, MDSC
Entity Type:Organization
Organization Name:TODD S. KIRK, MDSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:TODD
Authorized Official - Middle Name:S
Authorized Official - Last Name:KIRK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:708-857-7990
Mailing Address - Street 1:13303 S RIDGELAND AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:PALOS HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60463-1815
Mailing Address - Country:US
Mailing Address - Phone:708-857-7990
Mailing Address - Fax:708-857-7998
Practice Address - Street 1:13303 S RIDGELAND AVE
Practice Address - Street 2:SUITE B
Practice Address - City:PALOS HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60463-1815
Practice Address - Country:US
Practice Address - Phone:708-857-7990
Practice Address - Fax:708-857-7998
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-25
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036068842207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL777190Medicare PIN
ILD16542Medicare UPIN
0354830001Medicare NSC