1407119563 NPI number — TYLER R SELLERS PA-C

Table of content: TYLER R SELLERS PA-C (NPI 1407119563)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407119563 NPI number — TYLER R SELLERS PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SELLERS
Provider First Name:
TYLER
Provider Middle Name:
R
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1407119563
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/24/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
75 REMIT
Provider Second Line Business Mailing Address:
SUITE 1122
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60675-1122
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
866-916-5259
Provider Business Mailing Address Fax Number:
231-922-4030

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
335 GLESSNER AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MANSFIELD
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44903-2269
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
419-526-8000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/22/2012

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  50.003526 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)