Basic Information
| Provider Information | |||||||||
| NPI: | 1669453742 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | STITELY | ||||||||
| FirstName: | KEVIN | ||||||||
| MiddleName: | LEE | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 12622 | ||||||||
| Address2: | |||||||||
| City: | BELFAST | ||||||||
| State: | ME | ||||||||
| PostalCode: | 049154017 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4434816538 | ||||||||
| FaxNumber: | 4434816515 | ||||||||
| Practice Location | |||||||||
| Address1: | 29466 PINTAIL DR | ||||||||
| Address2: | SUITE 6 | ||||||||
| City: | EASTON | ||||||||
| State: | MD | ||||||||
| PostalCode: | 216019323 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4108224220 | ||||||||
| FaxNumber: | 4108224462 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/07/2005 | ||||||||
| LastUpdateDate: | 12/08/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0129X | D48064 | MD | Y | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery |
ID Information
| ID | Type | State | Issuer | Description | 852121200 | 05 | MD | MEDICAID | E4810003 | 01 | MD | CAREFIRST BLUECHOICE | OTHER | 232884 | 01 | MD | MAMSI | OTHER |