Provider Demographics
NPI:1093815342
Name:SELLETT, JOHN R (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:R
Last Name:SELLETT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 W. PARK. ST.
Mailing Address - Street 2:BWPC
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61801-2500
Mailing Address - Country:US
Mailing Address - Phone:217-383-6792
Mailing Address - Fax:217-383-4752
Practice Address - Street 1:1701 W CURTIS ROAD
Practice Address - Street 2:FAMILY MEDICINE/CONVENIENT CARE
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61822
Practice Address - Country:US
Practice Address - Phone:217-365-6201
Practice Address - Fax:217-326-1234
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2014-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036081168207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0533210001OtherDMERC
IL080043875OtherRAILROAD
IL0533210001OtherDMERC
ILL65298Medicare PIN
IL080043875OtherRAILROAD
ILIL3270216Medicare PIN
E68938Medicare UPIN