Provider Demographics
NPI:1669523346
Name:KIRWIN, MICHAEL (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:KIRWIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 E MAIN ST
Mailing Address - Street 2:STE 101
Mailing Address - City:MAHOMET
Mailing Address - State:IL
Mailing Address - Zip Code:61853-7460
Mailing Address - Country:US
Mailing Address - Phone:913-359-6001
Mailing Address - Fax:330-923-3507
Practice Address - Street 1:190 N UNION ST STE 203
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44304-1362
Practice Address - Country:US
Practice Address - Phone:330-923-3502
Practice Address - Fax:330-928-9761
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-16
Last Update Date:2022-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35046690207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000505994OtherANTHEM BCBS
OH0494488Medicaid
OH0494488Medicaid