Provider Demographics
NPI:1033236823
Name:WILLSON, SEANN ELISE (MD)
Entity Type:Individual
Prefix:
First Name:SEANN
Middle Name:ELISE
Last Name:WILLSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SEANN
Other - Middle Name:ELISE
Other - Last Name:CARR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:4466 W BRISTOL RD
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48507-3170
Mailing Address - Country:US
Mailing Address - Phone:810-733-1200
Mailing Address - Fax:810-733-0688
Practice Address - Street 1:4466 W BRISTOL RD
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48507-3170
Practice Address - Country:US
Practice Address - Phone:810-733-1200
Practice Address - Fax:810-733-0688
Is Sole Proprietor?:No
Enumeration Date:2007-03-25
Last Update Date:2012-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301091485207X00000X, 207XS0114X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XS0114XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryAdult Reconstructive Orthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1033236823Medicaid
MI0N45090OtherMEDICARE GROUP PTAN
MI0251416OtherBCBSM
MI0N45090OtherMEDICARE GROUP PTAN