Healthcare Provider Details

I. General information

NPI: 1023626751
Provider Name (Legal Business Name): KIRK ANTHONY STEWART MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2020
Last Update Date: 07/20/2020
Certification Date: 07/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 S HENNEPIN AVE
DIXON IL
61021-3013
US

IV. Provider business mailing address

102 S HENNEPIN AVE
DIXON IL
61021-3013
US

V. Phone/Fax

Practice location:
  • Phone: 815-285-8520
  • Fax: 815-285-8520
Mailing address:
  • Phone: 815-285-8520
  • Fax: 815-285-8520

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number125077218
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: