Provider Demographics
NPI:1649282120
Name:SEIDL, CALLIE A (PA)
Entity type:Individual
Prefix:
First Name:CALLIE
Middle Name:A
Last Name:SEIDL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:CALLIE
Other - Middle Name:
Other - Last Name:BEALS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:PO BOX 7112
Mailing Address - Street 2:DEPT. #31
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46207-7112
Mailing Address - Country:US
Mailing Address - Phone:317-802-3151
Mailing Address - Fax:317-870-0499
Practice Address - Street 1:8111 S EMERSON AVE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46237-8601
Practice Address - Country:US
Practice Address - Phone:317-528-5261
Practice Address - Fax:317-528-5026
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2021-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10000790363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q56972Medicare UPIN
IN339250B2Medicare PIN