Provider Demographics
NPI:1922207547
Name:KC, BIRENDRA (MD)
Entity Type:Individual
Prefix:
First Name:BIRENDRA
Middle Name:
Last Name:KC
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7015 A C SKINNER PKWY STE 1
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-6932
Mailing Address - Country:US
Mailing Address - Phone:904-363-2113
Mailing Address - Fax:904-363-2606
Practice Address - Street 1:9 SAN BARTOLA DR
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-5767
Practice Address - Country:US
Practice Address - Phone:904-825-4500
Practice Address - Fax:904-825-3672
Is Sole Proprietor?:No
Enumeration Date:2007-07-13
Last Update Date:2019-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2016-00813207R00000X
FLME140216207RH0003X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLIVC4KOtherFL BLUE
FL102868600Medicaid
FLLH202OtherMEDICARE
MIM74460147Medicare PIN