Provider Demographics
NPI:1053386789
Name:SELEDOTIS, ROBERT JOHN (DO, PC)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:JOHN
Last Name:SELEDOTIS
Suffix:
Gender:M
Credentials:DO, PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:560 W MITCHELL ST
Mailing Address - Street 2:SUITE 250
Mailing Address - City:PETOSKEY
Mailing Address - State:MI
Mailing Address - Zip Code:49770
Mailing Address - Country:US
Mailing Address - Phone:231-487-3182
Mailing Address - Fax:231-487-3249
Practice Address - Street 1:560 W MITCHELL ST
Practice Address - Street 2:SUITE 250
Practice Address - City:PETOSKEY
Practice Address - State:MI
Practice Address - Zip Code:49770
Practice Address - Country:US
Practice Address - Phone:231-487-3182
Practice Address - Fax:231-487-3249
Is Sole Proprietor?:No
Enumeration Date:2006-02-17
Last Update Date:2024-12-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5101013869207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
I17059Medicare UPIN
P00138408Medicare PIN
N98900001Medicare PIN