Healthcare Provider Details

I. General information

NPI: 1801886866
Provider Name (Legal Business Name): KRISTINE SELLBERG MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/21/2005
Last Update Date: 08/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5859 W TALAVI BLVD SUITE 100
GLENDALE AZ
85306
US

IV. Provider business mailing address

P.O. BOX 52886
PHOENIX AZ
85072
US

V. Phone/Fax

Practice location:
  • Phone: 602-298-7777
  • Fax: 623-930-6060
Mailing address:
  • Phone: 602-298-7777
  • Fax: 623-930-6060

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number29043
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number29043
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: