Individual
KELLIE DISTEFANO
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PA-C
Contact information
Practice address
525 S CENTER ST, HARTFORD, MI 49057-1362
(269) 621-4063
(269) 621-9972
Mailing address
400 MEDICAL PARK DR, WATERVLIET, MI 49098-9225
(269) 463-2431
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
5601002464
MI
363A00000X
Physician Assistant
5601002464
MI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
06116A
BHP PROVIDER ID #
MI
01
—
101465
GLHP PIN #
MI
01
—
381368745126
CCM BILLING # FOR PA-C
MI
01
—
KD002464
BCBS PROVIDER ID #
MI
01
—
KD09184
HPM PROVIDER ID #
MI
Enumeration date
04/19/2006
Last updated
12/18/2007
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