1669459905 NPI number — GERALD S STIPANUK MD

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669459905 NPI number — GERALD S STIPANUK MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
STIPANUK
Provider First Name:
GERALD
Provider Middle Name:
S
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1669459905
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/17/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
11/01/2017
NPI Reactivation Date:
11/21/2017

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
801 S MERIDIAN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GREENFIELD
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
38230-2104
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
731-235-0555
Provider Business Mailing Address Fax Number:
731-235-0559

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1520 N DIVISION ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BLYTHEVILLE
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72315-1448
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
731-235-0555
Provider Business Practice Location Address Fax Number:
731-235-0559
Provider Enumeration Date:
12/28/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208M00000X , with the licence number:  E-7145 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: E-7145 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0000006613645 . This is a "BCBS KY" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 4217156 . This is a "BCBS TN" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 1511734 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".




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