Basic Information
| Provider Information | |||||||||
| NPI: | 1922163476 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KNIRK | ||||||||
| FirstName: | JERRY | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7 GREENWOOD AVE | ||||||||
| Address2: | |||||||||
| City: | CONWAY | ||||||||
| State: | NH | ||||||||
| PostalCode: | 038186130 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6034473500 | ||||||||
| FaxNumber: | 6034475568 | ||||||||
| Practice Location | |||||||||
| Address1: | 7 GREENWOOD AVE | ||||||||
| Address2: | |||||||||
| City: | CONWAY | ||||||||
| State: | NH | ||||||||
| PostalCode: | 038186130 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6034473500 | ||||||||
| FaxNumber: | 6034475568 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/26/2006 | ||||||||
| LastUpdateDate: | 12/27/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 51343 | MA | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 3314165-002 | 01 | MA | CIGNA | OTHER | 6174132 | 05 | MA | MEDICAID | B141 | 01 | MA | HPHC | OTHER | 0014426 | 01 | MA | NHP | OTHER | 702853 | 01 | MA | TUFTS | OTHER |