Provider Demographics
NPI:1821279035
Name:KIRBY, MICHAEL T (CEO)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:T
Last Name:KIRBY
Suffix:
Gender:M
Credentials:CEO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:595 EDGEWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44307-2174
Mailing Address - Country:US
Mailing Address - Phone:330-671-9555
Mailing Address - Fax:234-542-1035
Practice Address - Street 1:595 EDGEWOOD AVE
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44307-2174
Practice Address - Country:US
Practice Address - Phone:330-671-9555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-15
Last Update Date:2020-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH7706227172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2752310Medicaid