Provider Demographics
NPI:1366472227
Name:KIRICENKOV, GEORGE (MD)
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:
Last Name:KIRICENKOV
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 1:100 CAPITOL COMMERCE BLVD
Mailing Address - Street 2:BLDG A SUITE 250
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36117-4260
Mailing Address - Country:US
Mailing Address - Phone:334-386-1420
Mailing Address - Fax:334-386-1478
Practice Address - Street 1:2815 E BLVD
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36116
Practice Address - Country:US
Practice Address - Phone:334-271-4545
Practice Address - Fax:334-271-6920
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2011-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL7556207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51556622KIRMedicare ID - Type Unspecified
C72477Medicare UPIN