Healthcare Provider Details

I. General information

NPI: 1184284606
Provider Name (Legal Business Name): BENJAMIN JAY KIRBY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2019
Last Update Date: 09/29/2024
Certification Date: 09/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 HOSPITAL DR RM M349
COLUMBIA MO
65212-1000
US

IV. Provider business mailing address

1 HOSPITAL DR RM M349
COLUMBIA MO
65212-1000
US

V. Phone/Fax

Practice location:
  • Phone: 573-882-2275
  • Fax:
Mailing address:
  • Phone: 573-882-2275
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number2019018904
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: