Healthcare Provider Details

I. General information

NPI: 1144330556
Provider Name (Legal Business Name): ANTHONY J KIRK DPM PC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 04/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2050 BRETON RD SE SUITE 105
GRAND RAPIDS MI
49546-5547
US

IV. Provider business mailing address

2050 BRETON RD SE SUITE 105
GRAND RAPIDS MI
49546-5547
US

V. Phone/Fax

Practice location:
  • Phone: 616-949-1524
  • Fax: 616-949-9472
Mailing address:
  • Phone: 616-949-1524
  • Fax: 616-949-9472

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberAK400050
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: