Provider Demographics
NPI:1386609543
Name:DISTEFANO, KELLIE (PA-C)
Entity type:Individual
Prefix:
First Name:KELLIE
Middle Name:
Last Name:DISTEFANO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 MEDICAL PARK DR
Mailing Address - Street 2:
Mailing Address - City:WATERVLIET
Mailing Address - State:MI
Mailing Address - Zip Code:49098-9225
Mailing Address - Country:US
Mailing Address - Phone:269-463-2431
Mailing Address - Fax:
Practice Address - Street 1:525 S CENTER ST
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:MI
Practice Address - Zip Code:49057-1362
Practice Address - Country:US
Practice Address - Phone:269-621-4063
Practice Address - Fax:269-621-9972
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2007-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601002464207Q00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI06116AOtherBHP PROVIDER ID #
MI381368745126OtherCCM BILLING # FOR PA-C
MI101465OtherGLHP PIN #
MIKD002464OtherBCBS PROVIDER ID #
MIKD09184OtherHPM PROVIDER ID #
MIOA16028Medicare ID - Type UnspecifiedSUPERVISING DRS ID #
MI101465OtherGLHP PIN #