Healthcare Provider Details

I. General information

NPI: 1306070529
Provider Name (Legal Business Name): ANITA BRIDGET SEBASTIAN D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2009
Last Update Date: 12/27/2024
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6116 NORTHLAND DR NE
ROCKFORD MI
49341
US

IV. Provider business mailing address

6116 NORTHLAND DR NE
ROCKFORD MI
49341
US

V. Phone/Fax

Practice location:
  • Phone: 616-259-6100
  • Fax: 616-259-5730
Mailing address:
  • Phone: 616-259-6100
  • Fax: 616-259-5730

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License NumberOT011300
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number5101020661
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: