NPIMap

Individual provider Active NPI

Kellie Distefano, PA-C

  • Family Medicine Physician
  • Hartford, MI
National Provider Identifier
1386609543
Registry record updated Dec 18, 2007
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
License
5601002464 Issued in MI
Practice address
525 S Center St
Hartford, MI 49057-1362
Phone
(269) 621-4063
Fax
(269) 621-9972
NPI assigned
Apr 19, 2006
Last updated
Dec 18, 2007By the provider in NPPES
Sex
Female
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Dec 18, 2007

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Physician Assistant 363A00000X 5601002464 MI
Family Medicine Physician 207Q00000X 5601002464 MI Primary

Addresses

Primary practice location

525 S Center St
Hartford, MI 49057-1362

Mailing address

400 Medical Park Dr
Watervliet, MI 49098-9225
Phone (269) 463-2431

Other identifiers 5

IdentifierTypeStateIssuer
06116AOtherMIBHP PROVIDER ID #
101465OtherMIGLHP PIN #
KD002464OtherMIBCBS PROVIDER ID #
381368745126OtherMICCM BILLING # FOR PA-C
KD09184OtherMIHPM PROVIDER ID #

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Not listed in the public Medicare enrollment file

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Not enrolled
HHS exclusion list flag
CMS’s directory marks this NPI as on an HHS exclusion list; no matching OIG record was found. The OIG exclusions file (LEIE) holds no record for this NPI, and the directory does not say which list the flag comes from. How exclusions are shown Confirm with the OIG exclusions search.
Credentials
Physician Assistant

Practice roles

OrganizationSpecialtyStatusNew patients
Bronson South Haven Hospital Family Medicine Past Accepting new patients
Bronson South Haven Hospital Past Accepting new patients
Lakeland Community Hospital Watervliet Past Accepting new patients
Lansing Urgent Care, PLC Past Accepting new patients
Kalamazoo Emergency Associates, PLC Past Accepting new patients

Organizations & group practices 5

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1145404800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1197936000000",
    "number": "1386609543",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "400 MEDICAL PARK DR",
            "city": "WATERVLIET",
            "state": "MI",
            "postal_code": "490989225",
            "telephone_number": "269-463-2431"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "525 S CENTER ST",
            "city": "HARTFORD",
            "state": "MI",
            "postal_code": "490571362",
            "telephone_number": "269-621-4063",
            "fax_number": "269-621-9972"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "DISTEFANO",
        "first_name": "KELLIE",
        "credential": "PA-C",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2006-04-19",
        "last_updated": "2007-12-18",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "MI",
            "license": "5601002464",
            "primary": false
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "MI",
            "license": "5601002464",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BHP PROVIDER ID #",
            "identifier": "06116A",
            "state": "MI"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "GLHP PIN #",
            "identifier": "101465",
            "state": "MI"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BCBS PROVIDER ID #",
            "identifier": "KD002464",
            "state": "MI"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "CCM BILLING # FOR PA-C",
            "identifier": "381368745126",
            "state": "MI"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "HPM PROVIDER ID #",
            "identifier": "KD09184",
            "state": "MI"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Hartford, MI

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 18, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.