Healthcare Provider Details

I. General information

NPI: 1972746048
Provider Name (Legal Business Name): TINA S. IPE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2009
Last Update Date: 11/22/2023
Certification Date: 11/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15300 KANIS RD
LITTLE ROCK AR
72223-2004
US

IV. Provider business mailing address

15300 KANIS RD
LITTLE ROCK AR
72223-2004
US

V. Phone/Fax

Practice location:
  • Phone: 817-689-5139
  • Fax:
Mailing address:
  • Phone: 817-689-5139
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZB0001X
TaxonomyBlood Banking & Transfusion Medicine Physician
License NumberE-12325
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code207ZC0006X
TaxonomyClinical Pathology Physician
License NumberE-12325
License Number StateAR
# 3
Primary TaxonomyY
Taxonomy Code207ZP0105X
TaxonomyClinical Pathology/Laboratory Medicine Physician
License NumberE-12325
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: