Provider Demographics
NPI:1528646742
Name:SAMUEL D VAN KIRK MD, INC
Entity type:Organization
Organization Name:SAMUEL D VAN KIRK MD, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:D
Authorized Official - Last Name:VAN KIRK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:530-247-0270
Mailing Address - Street 1:2139 AIRPARK DR
Mailing Address - Street 2:
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96001-2433
Mailing Address - Country:US
Mailing Address - Phone:530-247-0270
Mailing Address - Fax:530-247-0271
Practice Address - Street 1:2139 AIRPARK DR
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96001-2433
Practice Address - Country:US
Practice Address - Phone:530-247-0270
Practice Address - Fax:530-247-0271
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-30
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA86026OtherMEDICAL LICENSE
CAGR0094810Medicaid