Provider Demographics
NPI:1346494192
Name:SELBY, MICHAEL GRANT (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:GRANT
Last Name:SELBY
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 1:101 SKAGGS RD STE 302
Mailing Address - Street 2:
Mailing Address - City:BRANSON
Mailing Address - State:MO
Mailing Address - Zip Code:65616-2062
Mailing Address - Country:US
Mailing Address - Phone:417-334-8288
Mailing Address - Fax:417-334-6966
Practice Address - Street 1:101 SKAGGS RD, STE 302
Practice Address - Street 2:
Practice Address - City:BRANSON
Practice Address - State:MO
Practice Address - Zip Code:65616-2062
Practice Address - Country:US
Practice Address - Phone:417-334-8288
Practice Address - Fax:417-334-6966
Is Sole Proprietor?:No
Enumeration Date:2008-11-06
Last Update Date:2023-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014008959207R00000X, 207RN0300X, 207R00000X
MN52059207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR212205001Medicaid
MO2000014075Medicaid
KS201105660CMedicaid
MO1346494192Medicaid
MOMA2082536Medicare PIN
MOP01713409Medicare PIN