Provider Demographics
NPI:1255384616
Name:STIPANOV, MICHAEL A (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:A
Last Name:STIPANOV
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 440100
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37244-0100
Mailing Address - Country:US
Mailing Address - Phone:423-698-1844
Mailing Address - Fax:423-624-2226
Practice Address - Street 1:605 GLENWOOD DR
Practice Address - Street 2:SUITE 200
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37404-1130
Practice Address - Country:US
Practice Address - Phone:423-698-1844
Practice Address - Fax:423-624-2226
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2013-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD26565207RH0003X
GA047026207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3839412Medicaid
GA00823875AMedicaid
TN3839412Medicare ID - Type UnspecifiedPROVIDER #
GA83BBBRKMedicare ID - Type UnspecifiedPROVIDER #
GA00823875AMedicaid