Provider Demographics
NPI:1154307320
Name:KIP, PHELPS C (MD)
Entity Type:Individual
Prefix:DR
First Name:PHELPS
Middle Name:C
Last Name:KIP
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 1:6630 S MCCARRAN BLVD
Mailing Address - Street 2:SUITE A-4
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89509-6158
Mailing Address - Country:US
Mailing Address - Phone:775-828-2873
Mailing Address - Fax:775-828-2889
Practice Address - Street 1:6630 S MCCARRAN BLVD
Practice Address - Street 2:SUITE A-4
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89509-6158
Practice Address - Country:US
Practice Address - Phone:775-828-2873
Practice Address - Fax:775-828-2889
Is Sole Proprietor?:No
Enumeration Date:2005-12-20
Last Update Date:2010-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV6889207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the Spine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV002016857Medicaid
NV11040852OtherCAQH
NVF24357Medicare UPIN
NV002016857Medicaid