| Kellie Distefano, PA-C | |
|
525 S Center St, Hartford, MI 49057-1362 | |
| (269) 621-4063 | |
| (269) 621-9972 |
| Full Name | Kellie Distefano |
|---|---|
| Gender | Female |
| Speciality | Family Medicine |
| Location | 525 S Center St, Hartford, Michigan |
| Accepts Medicare Assignments | Does not participate in Medicare Program. She may not accept medicare assignment. |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1386609543 | NPI | - | NPPES |
| 06116A | Other | MI | BHP PROVIDER ID # |
| 381368745126 | Other | MI | CCM BILLING # FOR PA-C |
| 101465 | Other | MI | GLHP PIN # |
| KD002464 | Other | MI | BCBS PROVIDER ID # |
| KD09184 | Other | MI | HPM PROVIDER ID # |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 207Q00000X | Family Medicine | 5601002464 (Michigan) | Primary |
| 363A00000X | Physician Assistant | 5601002464 (Michigan) | Secondary |
| Mailing Address | Practice Location Address |
|---|---|
| Kellie Distefano, PA-C 400 Medical Park Dr, Watervliet, MI 49098-9225 Ph: (269) 463-2431 | Kellie Distefano, PA-C 525 S Center St, Hartford, MI 49057-1362 Ph: (269) 621-4063 |
Jay Shah, M.D. Family Medicine Medicare: Accepting Medicare Assignments Practice Location: 525 S Center St, Hartford, MI 49057 Phone: 269-463-3600 Fax: 269-621-9972 |