Basic Information
| Provider Information | |||||||||
| NPI: | 1730183591 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SELL | ||||||||
| FirstName: | JERRY | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 506 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | ROCKFORD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458829228 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4193633008 | ||||||||
| FaxNumber: | 4193632093 | ||||||||
| Practice Location | |||||||||
| Address1: | 506 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | ROCKFORD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458829228 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4193633008 | ||||||||
| FaxNumber: | 4193632093 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2005 | ||||||||
| LastUpdateDate: | 11/10/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 11/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 398291 | OH | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0349680 | 05 | OH | MEDICAID |