Basic Information
| Provider Information | |||||||||
| NPI: | 1518153402 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KIRK | ||||||||
| FirstName: | ANNA | ||||||||
| MiddleName: | WEISS | ||||||||
| NamePrefix: | |||||||||
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| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WEISS | ||||||||
| OtherFirstName: | ANNA | ||||||||
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| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 751649 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282751649 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437891620 | ||||||||
| FaxNumber: | 8437242440 | ||||||||
| Practice Location | |||||||||
| Address1: | 2270 ASHLEY CROSSING DR | ||||||||
| Address2: | STE 170 | ||||||||
| City: | CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294145732 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437633700 | ||||||||
| FaxNumber: | 8437633714 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/24/2007 | ||||||||
| LastUpdateDate: | 10/27/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 4301090716 | MI | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208000000X | 4301090716 | MI | N | Allopathic & Osteopathic Physicians | Pediatrics | 207R00000X | 33093 | SC | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208000000X | 33093 | SC | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | P00969047 | 01 | SC | RR MEDICARE ID-RSFPN | OTHER | 330939 | 05 | SC | MEDICAID |