Healthcare Provider Details

I. General information

NPI: 1063096360
Provider Name (Legal Business Name): STEVEN IPPOLITO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2021
Last Update Date: 07/01/2026
Certification Date: 07/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2550 S ASHLAND AVE
GREEN BAY WI
54304-5252
US

IV. Provider business mailing address

PO BOX 19642
SPRINGFIELD IL
62794-9642
US

V. Phone/Fax

Practice location:
  • Phone: 920-548-7337
  • Fax:
Mailing address:
  • Phone: 217-545-8229
  • Fax: 217-545-2275

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number125077591
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number87391-20
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number4301517357
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: