Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207Q00000X | Family Doctor | 036143805 | IL |
N | 207Q00000X | Family Doctor | 125.065628 | IL |
Y | 207QS0010X | Family Doctor - Sports Medicine | 036.143805 | IL |
NPI | 1265847941 |
---|---|
Provider Name | Spencer Kirk |
First Address | Aurora, IL 60506-1404 |
Second Address | Aurora, IL 60506-1404 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 22/06/2014 |
Last Update Date | 18/11/2021 |