Healthcare Provider Details

I. General information

NPI: 1649483645
Provider Name (Legal Business Name): MARY GRACE HIPOLITO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2007
Last Update Date: 10/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

560 GAGE BLVD SUITE 206
RICHLAND WA
99352
US

IV. Provider business mailing address

560 GAGE BLVD SUITE 203
RICHLAND WA
99352
US

V. Phone/Fax

Practice location:
  • Phone: 509-942-3286
  • Fax: 509-628-1354
Mailing address:
  • Phone: 509-942-3627
  • Fax: 509-942-2268

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD00047814
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: