Provider Demographics
NPI:1578872438
Name:ANTHONY J KIRK DPM PC
Entity Type:Organization
Organization Name:ANTHONY J KIRK DPM PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:PAT
Authorized Official - Middle Name:
Authorized Official - Last Name:GILLMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-949-1524
Mailing Address - Street 1:2050 BRETON RD SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-5547
Mailing Address - Country:US
Mailing Address - Phone:616-949-1524
Mailing Address - Fax:616-949-9472
Practice Address - Street 1:2050 BRETON RD SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-5547
Practice Address - Country:US
Practice Address - Phone:616-949-1524
Practice Address - Fax:616-949-9472
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-27
Last Update Date:2010-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAK400050261QP1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
4854111170OtherBCBS
MI4355335Medicaid
4854111170OtherBCBS
MI4355335Medicaid