Provider Demographics
NPI:1184631277
Name:ROBERT J SELEDOTIS DO PC INC
Entity type:Organization
Organization Name:ROBERT J SELEDOTIS DO PC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:SELEDOTIS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:616-454-9246
Mailing Address - Street 1:PO BOX 3140
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49501-3140
Mailing Address - Country:US
Mailing Address - Phone:616-454-9246
Mailing Address - Fax:616-454-6839
Practice Address - Street 1:847 PARCHMENT DR SE STE 125
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-8623
Practice Address - Country:US
Practice Address - Phone:616-454-9246
Practice Address - Fax:616-454-6839
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-02
Last Update Date:2019-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DB9450OtherRAILROAD MEDICARE
DB9450OtherRAILROAD MEDICARE