Provider Demographics
NPI:1104848662
Name:NELLESTEIN, MICHAEL E (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:E
Last Name:NELLESTEIN
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 1:1341 VILLAGE DR
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MO
Mailing Address - Zip Code:64506-2457
Mailing Address - Country:US
Mailing Address - Phone:816-291-4149
Mailing Address - Fax:816-897-3969
Practice Address - Street 1:1341 VILLAGE DR
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MO
Practice Address - Zip Code:64506-2457
Practice Address - Country:US
Practice Address - Phone:816-291-4149
Practice Address - Fax:816-897-3969
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-24
Last Update Date:2016-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO101630202K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes202K00000XAllopathic & Osteopathic PhysiciansPhlebology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO208881938Medicaid
G-63369Medicare UPIN
MOMA6280001Medicare PIN
KSB06000003Medicare PIN
KSP01348125Medicare PIN
KSB060000Medicare PIN
MO208881938Medicaid