Provider Demographics
NPI:1104865377
Name:KIPP, GARY S (MD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:S
Last Name:KIPP
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1061 HARMON AVE
Mailing Address - Street 2:
Mailing Address - City:FORT STEWART
Mailing Address - State:GA
Mailing Address - Zip Code:31314-5674
Mailing Address - Country:US
Mailing Address - Phone:912-435-6965
Mailing Address - Fax:
Practice Address - Street 1:1061 HARMON AVE
Practice Address - Street 2:
Practice Address - City:FORT STEWART
Practice Address - State:GA
Practice Address - Zip Code:31314-5674
Practice Address - Country:US
Practice Address - Phone:912-435-6965
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-05
Last Update Date:2015-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME110454207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00938748AMedicaid
FL003774800Medicaid
FLF1215ZMedicare PIN
GAG41423Medicare UPIN
GA16BBCCNMedicare ID - Type Unspecified