Basic Information
| Provider Information | |||||||||
| NPI: | 1851360606 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SELIOUTSKI | ||||||||
| FirstName: | ALEXANDER | ||||||||
| MiddleName: | Z | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 95 E CHAUTAUQUA ST | ||||||||
| Address2: | PO BOX 168 | ||||||||
| City: | MAYVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 147570168 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7167537107 | ||||||||
| FaxNumber: | 7167537980 | ||||||||
| Practice Location | |||||||||
| Address1: | 95 E CHAUTAUQUA ST | ||||||||
| Address2: | |||||||||
| City: | MAYVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 147570168 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7167537107 | ||||||||
| FaxNumber: | 7167537980 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/15/2006 | ||||||||
| LastUpdateDate: | 02/29/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 209688 | NY | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0110754 | 01 | NY | INDEPENDENT HEALTH | OTHER | 00020544403 | 01 | NY | UNIVERA | OTHER | 000525727007 | 01 | NY | BCBSWNY | OTHER | 01958516 | 05 | NY | MEDICAID |