Healthcare Provider Details

I. General information

NPI: 1922163476
Provider Name (Legal Business Name): JERRY L KNIRK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/26/2006
Last Update Date: 12/27/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7 GREENWOOD AVE
CONWAY NH
03818-6130
US

IV. Provider business mailing address

7 GREENWOOD AVE
CONWAY NH
03818-6130
US

V. Phone/Fax

Practice location:
  • Phone: 603-447-3500
  • Fax: 603-447-5568
Mailing address:
  • Phone: 603-447-3500
  • Fax: 603-447-5568

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number51343
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: