Basic Information
Provider Information | |||||||||
NPI: | 1962407254 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SEIDLER | ||||||||
FirstName: | JAY | ||||||||
MiddleName: | RICHARD | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | DO | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 751803 | ||||||||
Address2: |   | ||||||||
City: | CHARLOTTE | ||||||||
State: | NC | ||||||||
PostalCode: | 282751803 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3367196100 | ||||||||
FaxNumber: | 3367192313 | ||||||||
Practice Location | |||||||||
Address1: | 865 W LAKE DR | ||||||||
Address2: |   | ||||||||
City: | MOUNT AIRY | ||||||||
State: | NC | ||||||||
PostalCode: | 270302157 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3367196100 | ||||||||
FaxNumber: | 3367192313 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/15/2005 | ||||||||
LastUpdateDate: | 10/25/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/06/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 34007261 | OH | N |   | Allopathic & Osteopathic Physicians | Family Medicine |   | 207Q00000X | 2010-00404 | NC | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 5914840 | 05 | NC |   | MEDICAID | 1962407254 | 05 | VA |   | MEDICAID | 2252968 | 05 | OH |   | MEDICAID | 2001246000 | 05 | WV |   | MEDICAID |