Provider Demographics
NPI:1558304279
Name:DR. PAMELA KIRBY PA
Entity Type:Organization
Organization Name:DR. PAMELA KIRBY PA
Other - Org Name:DR. PAMELA KIRBY PA
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:E
Authorized Official - Last Name:KIRBY
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:386-788-4111
Mailing Address - Street 1:4606 S CLYDE MORRIS BLVD
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32129-7453
Mailing Address - Country:US
Mailing Address - Phone:386-788-4111
Mailing Address - Fax:386-788-4113
Practice Address - Street 1:4606 CLYDE MORRIS BLVD
Practice Address - Street 2:STUITE 1J
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32129
Practice Address - Country:US
Practice Address - Phone:386-788-4111
Practice Address - Fax:386-788-4113
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO2581213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU63831Medicare UPIN