Provider Demographics
NPI:1598952483
Name:TIMOTHY R KIRK OD PC
Entity Type:Organization
Organization Name:TIMOTHY R KIRK OD PC
Other - Org Name:TOWN & COUNTRY EYECARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:R
Authorized Official - Last Name:KIRK
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:248-347-7800
Mailing Address - Street 1:23850 HICKORY GROVE LN
Mailing Address - Street 2:
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48375-3162
Mailing Address - Country:US
Mailing Address - Phone:248-347-7800
Mailing Address - Fax:248-347-7801
Practice Address - Street 1:22350 NOVI RD
Practice Address - Street 2:
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48375-4708
Practice Address - Country:US
Practice Address - Phone:248-347-7800
Practice Address - Fax:248-347-7801
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-25
Last Update Date:2008-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003020152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ON61480OtherMEDICARE SUPPLIES DMERC
MI4901003852OtherOD LICENSE
MI900F310020OtherBCBS ID
MI4901003020OtherOD LICENSE
MI900F365750OtherBCBS ID
MI900F310020OtherBCBS ID
MI4901003020OtherOD LICENSE
MI0950520001Medicare NSC
MIU35446Medicare UPIN
MIN61480001Medicare PIN