Basic Information
Provider Information | |||||||||
NPI: | 1053379156 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KIRKLAND | ||||||||
FirstName: | STEPHEN | ||||||||
MiddleName: | MITCHELL | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1701 WESTCHESTER DRIVE | ||||||||
Address2: | SUITE 850 | ||||||||
City: | HIGH POINT | ||||||||
State: | NC | ||||||||
PostalCode: | 272627254 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3368022400 | ||||||||
FaxNumber: | 3368022001 | ||||||||
Practice Location | |||||||||
Address1: | 3073 TRENWEST DR | ||||||||
Address2: |   | ||||||||
City: | WINSTON-SALEM | ||||||||
State: | NC | ||||||||
PostalCode: | 271033207 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3367680437 | ||||||||
FaxNumber: | 3367680433 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/01/2006 | ||||||||
LastUpdateDate: | 06/23/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 30052 | NC | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
ID | Type | State | Issuer | Description | 39145 | 01 | NC | MEDCOST | OTHER | 283800C | 01 | NC | MPH PROVIDER NUMBER | OTHER | 49304 | 01 | NC | BCNC | OTHER | 5015101002 | 01 | NC | CIGNA | OTHER | 8949304 | 05 | NC |   | MEDICAID | 2502155 | 01 | NC | UNITED HEALTH CARE | OTHER | 4099307 | 01 | NC | AETNA | OTHER | P00654533 | 01 | NC | RAILROAD MEDICARE | OTHER | 759 | 01 | NC | PARTNERS MEDICARE | OTHER | 060012391 | 01 | NC | RAILROAD MEDICARE | OTHER | 203800D | 01 | NC | FMC PROVIDER NUMBER | OTHER | 216756 | 01 | NC | MAMSI | OTHER |