MEDICARE: DR. JENNIFER KIRSTEN KIRK MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208600000X	Surgery Physician	036090372	IL

General Provider Information

NPI Number	:	1679564397
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JENNIFER KIRSTEN KIRK MD

Provider Business Mailing Address
First Line	:	630 E NORTH AVE
Second Line	:
City	:	CAROL STREAM
State	:	IL
Zip	:	60188-2127
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	630 E NORTH AVE
Second Line	:
City	:	CAROL STREAM
State	:	IL
Zip	:	60188-2127
Country	:	US
Telephone Number	:	630-458-5300
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/02/2005
Last Update Date	:	03/11/2019

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