Provider Demographics
NPI:1104897065
Name:SELLERGREN, KIM R (MD)
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:R
Last Name:SELLERGREN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 91734
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23291-1734
Mailing Address - Country:US
Mailing Address - Phone:804-358-6100
Mailing Address - Fax:804-342-7619
Practice Address - Street 1:1250 E MARSHALL STREET
Practice Address - Street 2:ORTHOPAEDIC SURGERY
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23298-0510
Practice Address - Country:US
Practice Address - Phone:804-828-7069
Practice Address - Fax:804-828-7199
Is Sole Proprietor?:No
Enumeration Date:2006-01-30
Last Update Date:2009-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101038013207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0101038013OtherLICENSE
VA427693OtherMAMSI
VA0593050001OtherMEDICARE DME
VA4063751OtherAETNA NON HMO
VA2427354OtherAETNA HMO
VACA9037OtherMCR RAILROAD GROUP
VA006400957Medicaid
VA140405OtherANTHEM
VAC02375OtherMEDICARE GROUP
VA200040112Medicare PIN
VA140405OtherANTHEM
VA4063751OtherAETNA NON HMO