=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811955560
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TODD S KIRK MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/03/2006
-----------------------------------------------------
Last Update Date | 08/15/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13303 S RIDGELAND AVE SUITE B
-----------------------------------------------------
City | PALOS HEIGHTS
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60463-1815
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-857-7990
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13303 S RIDGELAND AVE SUITE B
-----------------------------------------------------
City | PALOS HEIGHTS
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60463-1815
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-857-7990
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207W00000X
-----------------------------------------------------
Taxonomy Name | Ophthalmology Physician
-----------------------------------------------------
License Number | 036068842
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------