Healthcare Provider Details

I. General information

NPI: 1235165929
Provider Name (Legal Business Name): EDWARD KIRSH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2006
Last Update Date: 11/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

966 W 21ST ST
CHICAGO IL
60608
US

IV. Provider business mailing address

966 W 21ST ST
CHICAGO IL
60608-4511
US

V. Phone/Fax

Practice location:
  • Phone: 773-254-1400
  • Fax: 312-829-6842
Mailing address:
  • Phone: 773-254-1400
  • Fax: 312-829-6842

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number036-094001
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: