Provider Demographics
NPI:1609955400
Name:FITZGERALD, STEPHANIE LYNNE (DO)
Entity type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:LYNNE
Last Name:FITZGERALD
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1293 E PARKDALE AVE
Mailing Address - Street 2:SUITE 1200A
Mailing Address - City:MANISTEE
Mailing Address - State:MI
Mailing Address - Zip Code:49660-8904
Mailing Address - Country:US
Mailing Address - Phone:231-398-1550
Mailing Address - Fax:231-398-1691
Practice Address - Street 1:1293 E PARKDALE AVE
Practice Address - Street 2:SUITE 1200A
Practice Address - City:MANISTEE
Practice Address - State:MI
Practice Address - Zip Code:49660-8904
Practice Address - Country:US
Practice Address - Phone:231-398-1550
Practice Address - Fax:231-398-1691
Is Sole Proprietor?:No
Enumeration Date:2006-11-03
Last Update Date:2020-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101012161207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1655100055OtherBLUE CARE NETWORK
MI1655100055OtherBCBS
MI700E110080OtherGROUP BCBS
MI4074432Medicaid
MI1655100055OtherBLUE CARE NETWORK
MI0P29960011Medicare PIN
MIG54661Medicare UPIN
MI4074432Medicaid