Healthcare Provider Details

I. General information

NPI: 1982753067
Provider Name (Legal Business Name): JACK D. SELZER, M.D. AND ASSOCIATES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/09/2007
Last Update Date: 10/31/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10495 MONTGOMERY RD STE 26
CINCINNATI OH
45242-4420
US

IV. Provider business mailing address

10495 MONTGOMERY RD STE 26
CINCINNATI OH
45242-4420
US

V. Phone/Fax

Practice location:
  • Phone: 513-891-7265
  • Fax: 513-745-4512
Mailing address:
  • Phone: 513-891-7265
  • Fax: 513-745-4512

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number35018919
License Number StateOH

VIII. Authorized Official

Name: DR. JACK D. SELZER
Title or Position: PRESIDENT
Credential: M.D.
Phone: 513-891-7265