Healthcare Provider Details

I. General information

NPI: 1922097492
Provider Name (Legal Business Name): STEPHEN L KIRKNER D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2005
Last Update Date: 03/28/2021
Certification Date: 03/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 TENEYCK ST SUITE 100
JACKSON MI
49201-2461
US

IV. Provider business mailing address

1111 TENEYCK ST SUITE 100
JACKSON MI
49201-2461
US

V. Phone/Fax

Practice location:
  • Phone: 517-787-8940
  • Fax: 517-787-9054
Mailing address:
  • Phone: 517-787-8940
  • Fax: 517-787-9054

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number5101007908
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: