Basic Information
| Provider Information | |||||||||
| NPI: | 1598952483 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TIMOTHY R KIRK OD PC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | TOWN & COUNTRY EYECARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 23850 HICKORY GROVE LN | ||||||||
| Address2: | |||||||||
| City: | NOVI | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483753162 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2483477800 | ||||||||
| FaxNumber: | 2483477801 | ||||||||
| Practice Location | |||||||||
| Address1: | 22350 NOVI RD | ||||||||
| Address2: | |||||||||
| City: | NOVI | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483754708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2483477800 | ||||||||
| FaxNumber: | 2483477801 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/25/2007 | ||||||||
| LastUpdateDate: | 12/09/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KIRK | ||||||||
| AuthorizedOfficialFirstName: | TIMOTHY | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2483477800 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | O.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 4901003020 | MI | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | ON61480 | 01 | MEDICARE SUPPLIES DMERC | OTHER | 4901003852 | 01 | MI | OD LICENSE | OTHER | 900F310020 | 01 | MI | BCBS ID | OTHER | 4901003020 | 01 | MI | OD LICENSE | OTHER | 900F365750 | 01 | MI | BCBS ID | OTHER |