Healthcare Provider Details

I. General information

NPI: 1427406701
Provider Name (Legal Business Name): KELLEN GARY HIPP D.O
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2016
Last Update Date: 07/19/2022
Certification Date: 07/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9 HEALTHCARE DR STE 202
BIDDEFORD ME
04005-9450
US

IV. Provider business mailing address

22250 PROVIDENCE DR
SOUTHFIELD MI
48075-4825
US

V. Phone/Fax

Practice location:
  • Phone: 207-283-1427
  • Fax:
Mailing address:
  • Phone: 248-849-3281
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberDO3387
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: