Healthcare Provider Details

I. General information

NPI: 1750342028
Provider Name (Legal Business Name): ALEXANDER SELIVERSTOV MD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/28/2006
Last Update Date: 11/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18300 ROSCOE BLVD
NORTHRIDGE CA
91325-4105
US

IV. Provider business mailing address

PO BOX 7001
TARZANA CA
91357-7001
US

V. Phone/Fax

Practice location:
  • Phone: 818-885-8500
  • Fax: 818-715-1722
Mailing address:
  • Phone: 818-888-7815
  • Fax: 818-715-1722

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License NumberA76611
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberA76611
License Number StateCA

VIII. Authorized Official

Name: ALEXANDER SELIVERSTOV
Title or Position: SOLE OWNER
Credential: M.D.
Phone: 818-888-7815