Provider Demographics
NPI:1962685743
Name:MICHELE L SELSOR INC
Entity Type:Organization
Organization Name:MICHELE L SELSOR INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHELE
Authorized Official - Middle Name:L
Authorized Official - Last Name:SELSOR
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:727-321-9488
Mailing Address - Street 1:4104 5TH AVE N
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33713-6304
Mailing Address - Country:US
Mailing Address - Phone:727-321-9488
Mailing Address - Fax:727-321-2033
Practice Address - Street 1:4104 5TH AVE N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33713-6304
Practice Address - Country:US
Practice Address - Phone:727-321-9488
Practice Address - Fax:727-321-2033
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-14
Last Update Date:2010-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO2916213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL340214200Medicaid
FL4687950002Medicare NSC