Provider Demographics
NPI:1669453742
Name:STITELY, KEVIN LEE (MD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:LEE
Last Name:STITELY
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:PO BOX 12622
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-4017
Mailing Address - Country:US
Mailing Address - Phone:443-481-6538
Mailing Address - Fax:443-481-6515
Practice Address - Street 1:29466 PINTAIL DR
Practice Address - Street 2:SUITE 6
Practice Address - City:EASTON
Practice Address - State:MD
Practice Address - Zip Code:21601-9323
Practice Address - Country:US
Practice Address - Phone:410-822-4220
Practice Address - Fax:410-822-4462
Is Sole Proprietor?:No
Enumeration Date:2005-11-07
Last Update Date:2013-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD480642086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD852121200Medicaid
MDE4810003OtherCAREFIRST BLUECHOICE
MD232884OtherMAMSI
MDS000Medicare ID - Type Unspecified
MD079NMedicare ID - Type Unspecified
F09940Medicare UPIN
MD852121200Medicaid
KQ62ZDWSMedicare PIN