Provider Demographics
NPI:1669459905
Name:STIPANUK, GERALD S (MD)
Entity Type:Individual
Prefix:
First Name:GERALD
Middle Name:S
Last Name:STIPANUK
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 1:801 S MERIDIAN ST
Mailing Address - Street 2:
Mailing Address - City:GREENFIELD
Mailing Address - State:TN
Mailing Address - Zip Code:38230-2104
Mailing Address - Country:US
Mailing Address - Phone:731-235-0555
Mailing Address - Fax:731-235-0559
Practice Address - Street 1:1520 N DIVISION ST
Practice Address - Street 2:
Practice Address - City:BLYTHEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72315-1448
Practice Address - Country:US
Practice Address - Phone:731-235-0555
Practice Address - Fax:731-235-0559
Is Sole Proprietor?:No
Enumeration Date:2005-12-28
Last Update Date:2018-03-17
Deactivation Date:2017-11-01
Deactivation Code:
Reactivation Date:2017-11-21
Provider Licenses
StateLicense IDTaxonomies
ARE-7145208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY0000006613645OtherBCBS KY
TN4217156OtherBCBS TN
TN1511734Medicaid
KY0000006613645OtherBCBS KY
B46329Medicare UPIN