Healthcare Provider Details

I. General information

NPI: 1134819386
Provider Name (Legal Business Name): MR. AUSTIN KIRBY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/10/2023
Last Update Date: 05/10/2023
Certification Date: 05/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 PARK AVE
SAINT LOUIS MO
63104-3024
US

IV. Provider business mailing address

701 W SCOTT ST APT 5
KIRKSVILLE MO
63501-1555
US

V. Phone/Fax

Practice location:
  • Phone: 866-626-2878
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: