Healthcare Provider Details

I. General information

NPI: 1922207547
Provider Name (Legal Business Name): BIRENDRA KC MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2007
Last Update Date: 10/29/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9 SAN BARTOLA DR
ST AUGUSTINE FL
32086-5767
US

IV. Provider business mailing address

7015 A C SKINNER PKWY STE 1
JACKSONVILLE FL
32256-6932
US

V. Phone/Fax

Practice location:
  • Phone: 904-825-4500
  • Fax: 904-825-3672
Mailing address:
  • Phone: 904-363-2113
  • Fax: 904-363-2606

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2016-00813
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License NumberME140216
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: