Provider Demographics
NPI:1528006798
Name:SELLBERG, MARTIN E (MD)
Entity Type:Individual
Prefix:
First Name:MARTIN
Middle Name:E
Last Name:SELLBERG
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 1:3521 W BAYVIEW CT
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67204-2377
Mailing Address - Country:US
Mailing Address - Phone:316-619-4450
Mailing Address - Fax:
Practice Address - Street 1:1124 W 21ST ST
Practice Address - Street 2:
Practice Address - City:ANDOVER
Practice Address - State:KS
Practice Address - Zip Code:67002
Practice Address - Country:US
Practice Address - Phone:316-300-4000
Practice Address - Fax:316-300-4940
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-21478207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS103435Medicare ID - Type Unspecified
KSB91276Medicare UPIN