Provider Demographics
NPI:1417043886
Name:WILLIAM D. KIRK M.D., PLLC
Entity Type:Organization
Organization Name:WILLIAM D. KIRK M.D., PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:DEADRICK
Authorized Official - Last Name:KIRK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:270-692-9559
Mailing Address - Street 1:312 W HIGH ST
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:KY
Mailing Address - Zip Code:40033-1428
Mailing Address - Country:US
Mailing Address - Phone:270-692-9559
Mailing Address - Fax:270-692-9236
Practice Address - Street 1:312 W HIGH ST
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:KY
Practice Address - Zip Code:40033-1428
Practice Address - Country:US
Practice Address - Phone:270-692-9559
Practice Address - Fax:270-692-9236
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-05
Last Update Date:2015-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY103TC0700X
KY26011207Q00000X, 207R00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY9590111200Medicaid
KY50001390OtherPASSPORT
KY2442987001OtherPASSPORT ADVANTAGE
KY78903242Medicaid
KYC74393Medicare UPIN
KY9590111200Medicaid