Provider Demographics
NPI:1710015011
Name:KIPPES, GLENN A
Entity Type:Individual
Prefix:MR
First Name:GLENN
Middle Name:A
Last Name:KIPPES
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 1:6588 N ORACLE RD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85704-5615
Mailing Address - Country:US
Mailing Address - Phone:520-575-8538
Mailing Address - Fax:520-797-2169
Practice Address - Street 1:6588 N ORACLE RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85704-5615
Practice Address - Country:US
Practice Address - Phone:520-575-8538
Practice Address - Fax:520-797-2169
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZPT4062251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZRPT406Medicare ID - Type UnspecifiedMEDICARE IDENTIFIER