Provider Demographics
NPI:1679892996
Name:PAMELA KIRBY PA
Entity Type:Organization
Organization Name:PAMELA KIRBY PA
Other - Org Name:DR PAMEL KIRBY DPM
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:
Authorized Official - Last Name:KIBRY
Authorized Official - Suffix:
Authorized Official - Credentials:DOM
Authorized Official - Phone:386-788-4111
Mailing Address - Street 1:4606 SOUTH CLYDE MORRIS BOULEVARD
Mailing Address - Street 2:SUITE 1J
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32129
Mailing Address - Country:US
Mailing Address - Phone:386-788-4111
Mailing Address - Fax:386-788-4113
Practice Address - Street 1:4606 SOUTH CLYDE MORRIS BOULEVARD
Practice Address - Street 2:SUITE 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:2010-05-26
Last Update Date:2010-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QH0100X
FLAP2222261QM2500X
FLPO0002581261QP1100X
FLPO3308261QP1100X
FLPO2796261QP1100X
FLPT17909261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1160660001Medicare NSC