Provider Demographics
NPI:1235158098
Name:KIRK, SCOTT HAROLD (MD)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:HAROLD
Last Name:KIRK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7427 LAKE ST
Mailing Address - Street 2:
Mailing Address - City:RIVER FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60305-1817
Mailing Address - Country:US
Mailing Address - Phone:708-771-3334
Mailing Address - Fax:708-771-9614
Practice Address - Street 1:7427 LAKE ST
Practice Address - Street 2:
Practice Address - City:RIVER FOREST
Practice Address - State:IL
Practice Address - Zip Code:60305-1817
Practice Address - Country:US
Practice Address - Phone:708-771-3334
Practice Address - Fax:708-771-9614
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2023-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036059716207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL362658561OtherFED TAX ID #
IL36059716Medicaid
IL1607956OtherBC/BS ILLINOIS
ILC40674Medicare UPIN