1073661401 NPI number — STEVEN R SELLA DPM PLLC

Table of content: (NPI 1073661401)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073661401 NPI number — STEVEN R SELLA DPM PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STEVEN R SELLA DPM PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1073661401
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/10/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
854 N CENTER AVE
Provider Second Line Business Mailing Address:
STE 2
Provider Business Mailing Address City Name:
GAYLORD
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49735-1686
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
989-732-0570
Provider Business Mailing Address Fax Number:
989-732-0512

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
854 N CENTER AVE
Provider Second Line Business Practice Location Address:
STE 2
Provider Business Practice Location Address City Name:
GAYLORD
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49735-1686
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
989-732-0570
Provider Business Practice Location Address Fax Number:
989-732-0512
Provider Enumeration Date:
01/08/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SELLA
Authorized Official First Name:
STEVEN
Authorized Official Middle Name:
RICHARD
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
989-732-0570

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X , with the licence number:  SS001770 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: M035440 . This is a "CHAMPUS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: P88770 . This is a "BLUE CARE NETWORK" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 3408855 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4856910190 . This is a "BC BS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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