Provider Demographics
NPI:1245226380
Name:AGERSON, KIRK JOSEPH (MD)
Entity Type:Individual
Prefix:DR
First Name:KIRK
Middle Name:JOSEPH
Last Name:AGERSON
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 1:2849 MICHIGAN ST NE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49506-1216
Mailing Address - Country:US
Mailing Address - Phone:616-285-6450
Mailing Address - Fax:616-285-6455
Practice Address - Street 1:2849 MICHIGAN ST NE
Practice Address - Street 2:SUITE 102
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49506-1216
Practice Address - Country:US
Practice Address - Phone:616-285-6450
Practice Address - Fax:616-285-6455
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301041396207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0804100171OtherBLUE CROSS BLUE SHIELD
MIB47167Medicare UPIN
MI0804100171OtherBLUE CROSS BLUE SHIELD