MEDICARE: ANTHONY J KIRK DPM PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QP1100X	Podiatric Clinic/Center	AK400050	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	4854111170	OTHER		BCBS
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1578872438
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ANTHONY J KIRK DPM PC

Provider Business Mailing Address
First Line	:	2050 BRETON RD SE
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49546-5547
Country	:	US
Telephone Number	:	616-949-1524
Fax Number	:	616-949-9472

Provider Business Practice Location Address
First Line	:	2050 BRETON RD SE
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49546-5547
Country	:	US
Telephone Number	:	616-949-1524
Fax Number	:	616-949-9472

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	MS. PAT GILLMAN
Credential	:
Telephone Number	:	616-949-1524

Provider Enumeration Date	:	09/27/2010
Last Update Date	:	09/27/2010

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