Provider Demographics
NPI:1417489469
Name:STIPEK, KATHLEEN
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:STIPEK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2142 N COVE BLVD
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43606-3895
Mailing Address - Country:US
Mailing Address - Phone:419-291-4000
Mailing Address - Fax:
Practice Address - Street 1:2142 N COVE BLVD
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43606-3895
Practice Address - Country:US
Practice Address - Phone:419-291-4000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-29
Last Update Date:2023-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI390200000X
OH34.015136207P00000X
MI5101026183207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program