Provider Demographics
NPI:1376572123
Name:LIPPINCOTT, CHARLES KENNETH
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:KENNETH
Last Name:LIPPINCOTT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4428 SOUTH EASON BOULEVARD
Mailing Address - Street 2:SUITE A
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38801-6506
Mailing Address - Country:US
Mailing Address - Phone:662-844-3739
Mailing Address - Fax:662-844-3728
Practice Address - Street 1:4428 SOUTH EASON BOULEVARD
Practice Address - Street 2:SUITE A
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38801-6506
Practice Address - Country:US
Practice Address - Phone:662-844-3739
Practice Address - Fax:662-844-3728
Is Sole Proprietor?:No
Enumeration Date:2006-07-02
Last Update Date:2013-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS091482084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00126957Medicaid
MSP00093379OtherRAILROAD MEDICARE
MSB65979Medicare UPIN
MS260000598Medicare PIN