Provider Demographics
NPI:1477726222
Name:MARK SEBY MD PC
Entity Type:Organization
Organization Name:MARK SEBY MD PC
Other - Org Name:AGASSIZ FAMILY MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:VINCENT
Authorized Official - Last Name:SEBY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:928-779-6169
Mailing Address - Street 1:417 N AGASSIZ ST
Mailing Address - Street 2:BLDG #1
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-3282
Mailing Address - Country:US
Mailing Address - Phone:928-779-6169
Mailing Address - Fax:928-779-4200
Practice Address - Street 1:417 N AGASSIZ ST
Practice Address - Street 2:BLDG #1
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-3282
Practice Address - Country:US
Practice Address - Phone:928-779-6169
Practice Address - Fax:928-779-4200
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-11
Last Update Date:2010-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAZ11476207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ080008588OtherRAILROAD MEDICARE
AZ5447372OtherAETNA
AZ87726OtherUNITED HEALTHCARE
AZ3323257OtherCIGNA
AZ1Z8845OtherHEALTHNET AZ
AZ188857300OtherUS DEPT OF LABOR
AZ23957601Medicaid
AZ71412OtherMUTUAL OF OMAHA
AZAZ0021730OtherBLUE CROSS BLUE SHIELD AZ
AZ1Z8845OtherHEALTHNET AZ
AZZ63389Medicare PIN