Healthcare Provider Details

I. General information

NPI: 1669453742
Provider Name (Legal Business Name): KEVIN LEE STITELY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2005
Last Update Date: 12/08/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29466 PINTAIL DR SUITE 6
EASTON MD
21601-9323
US

IV. Provider business mailing address

PO BOX 12622
BELFAST ME
04915-4017
US

V. Phone/Fax

Practice location:
  • Phone: 410-822-4220
  • Fax: 410-822-4462
Mailing address:
  • Phone: 443-481-6538
  • Fax: 443-481-6515

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberD48064
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: