Healthcare Provider Details

I. General information

NPI: 1467747774
Provider Name (Legal Business Name): MICHAEL J KIRBY MD PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/15/2011
Last Update Date: 06/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

445 N FENWAY DR
FENTON MI
48430-2666
US

IV. Provider business mailing address

445 N FENWAY DR
FENTON MI
48430-2666
US

V. Phone/Fax

Practice location:
  • Phone: 810-750-6060
  • Fax: 810-750-6081
Mailing address:
  • Phone: 810-750-6060
  • Fax: 810-750-6081

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301080170
License Number StateMI

VIII. Authorized Official

Name: MICHAEL J KIRBY
Title or Position: OWNER
Credential: MD
Phone: 810-750-6060