Healthcare Provider Details

I. General information

NPI: 1720087836
Provider Name (Legal Business Name): MICHAEL GENE KIDD M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2005
Last Update Date: 02/20/2023
Certification Date: 02/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

LANSTUHL REGIONAL MEDICAL CENTER UNIT 33100
APO AE
09180
US

IV. Provider business mailing address

11722 NC 41 HWY W
BLADENBORO NC
28320-7826
US

V. Phone/Fax

Practice location:
  • Phone: 910-374-9721
  • Fax:
Mailing address:
  • Phone: 910-374-9721
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number33076
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number33076
License Number StateNC
# 3
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number33076
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: