Basic Information
Provider Information | |||||||||
NPI: | 1760464705 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SEIDEN | ||||||||
FirstName: | MICHAEL | ||||||||
MiddleName: | V. | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 911230 | ||||||||
Address2: |   | ||||||||
City: | DALLAS | ||||||||
State: | TX | ||||||||
PostalCode: | 753911230 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9729978000 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 9200 PINECROFT DR STE 450 | ||||||||
Address2: |   | ||||||||
City: | SHENANDOAH | ||||||||
State: | TX | ||||||||
PostalCode: | 773803280 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2812960365 | ||||||||
FaxNumber: | 2812988907 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/16/2005 | ||||||||
LastUpdateDate: | 08/18/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 71183 | MA | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207RX0202X | 71183 | MA | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Medical Oncology | 207RX0202X | MD432386 | PA | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Medical Oncology | 207RX0202X | P8997 | TX | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Medical Oncology |
ID Information
ID | Type | State | Issuer | Description | 3122026 | 05 | MA |   | MEDICAID | 333013601 | 05 | TX |   | MEDICAID | J09299 | 01 | MA | BCBS MA | OTHER | 071183 | 01 | MA | TUFTS HEALTH PLAN | OTHER | 0102213389001 | 05 | PA |   | MEDICAID |