Provider Demographics
NPI:1184614257
Name:DISE, KIRK R (MD)
Entity type:Individual
Prefix:DR
First Name:KIRK
Middle Name:R
Last Name:DISE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:133 E FREDERICK ST
Mailing Address - Street 2:LANCASTER
Mailing Address - City:LANCASTER
Mailing Address - State:PA
Mailing Address - Zip Code:17602-2222
Mailing Address - Country:US
Mailing Address - Phone:717-394-9821
Mailing Address - Fax:717-394-0175
Practice Address - Street 1:133 E FREDERICK ST
Practice Address - Street 2:LANCASTER
Practice Address - City:LANCASTER
Practice Address - State:PA
Practice Address - Zip Code:17602-2222
Practice Address - Country:US
Practice Address - Phone:717-394-9821
Practice Address - Fax:717-394-0175
Is Sole Proprietor?:No
Enumeration Date:2005-10-28
Last Update Date:2007-07-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAMD-073141-L207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0018378690001Medicaid
PAH35340Medicare UPIN
PA0018378690001Medicaid