Basic Information
| Provider Information | |||||||||
| NPI: | 1245203645 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SELIM | ||||||||
| FirstName: | GHIULSER | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3960 PATIENT CARE WAY | ||||||||
| Address2: | SUITE 108 | ||||||||
| City: | LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 489114275 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5173948589 | ||||||||
| FaxNumber: | 5173948594 | ||||||||
| Practice Location | |||||||||
| Address1: | 3960 PATIENT CARE WAY | ||||||||
| Address2: | SUITE 108 | ||||||||
| City: | LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 489114275 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5173948589 | ||||||||
| FaxNumber: | 5173948594 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/08/2006 | ||||||||
| LastUpdateDate: | 01/19/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 4301059739 | MI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0331120 | 01 | MI | BCBS | OTHER | 4565575 | 05 | MI | MEDICAID |