Healthcare Provider Details

I. General information

NPI: 1518183789
Provider Name (Legal Business Name): BRYAN P KIRBY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2007
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 CLINIC AVE STE 101
CARROLLTON GA
30117-4402
US

IV. Provider business mailing address

150 CLINIC AVENUE SUITE 101
CARROLLTON GA
30117
US

V. Phone/Fax

Practice location:
  • Phone: 770-834-0873
  • Fax: 770-834-0873
Mailing address:
  • Phone: 770-834-0873
  • Fax: 770-834-6118

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number058688
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number058688
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: