Healthcare Provider Details

I. General information

NPI: 1851067300
Provider Name (Legal Business Name): SELVAN MD A PROFESSIONAL MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/16/2021
Last Update Date: 08/16/2021
Certification Date: 08/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3630 E IMPERIAL HWY
LYNWOOD CA
90262-2609
US

IV. Provider business mailing address

3705 W PICO BLVD # 991
LOS ANGELES CA
90019-3451
US

V. Phone/Fax

Practice location:
  • Phone: 310-900-8900
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084A2900X
TaxonomyNeurocritical Care Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2084V0102X
TaxonomyVascular Neurology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: PRADEEP SELVAN
Title or Position: CEO
Credential: MD
Phone: 267-391-7459