Provider Demographics
NPI:1245312537
Name:RIPP, KENNETH M (MD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:M
Last Name:RIPP
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 1:417 SKYLINE BLVD
Mailing Address - Street 2:
Mailing Address - City:CLOQUET
Mailing Address - State:MN
Mailing Address - Zip Code:55720-1164
Mailing Address - Country:US
Mailing Address - Phone:218-879-1271
Mailing Address - Fax:218-879-8904
Practice Address - Street 1:417 SKYLINE BLVD
Practice Address - Street 2:
Practice Address - City:CLOQUET
Practice Address - State:MN
Practice Address - Zip Code:55720-1164
Practice Address - Country:US
Practice Address - Phone:218-879-1271
Practice Address - Fax:218-879-8904
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2020-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN38473207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN892025700Medicaid
MN0102377OtherMEDICA
MN8D694RIOtherBLUES & FIRST PLAN
MN892025700Medicaid
MN8D694RIOtherBLUES & FIRST PLAN