Healthcare Provider Details

I. General information

NPI: 1164427183
Provider Name (Legal Business Name): MYLAPPAN SELVARAJ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/16/2005
Last Update Date: 10/23/2020
Certification Date: 10/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

777 NORTH ST
PITTSFIELD MA
01201-4147
US

IV. Provider business mailing address

109 WINTERWOOD DR
BUTLER PA
16001-2833
US

V. Phone/Fax

Practice location:
  • Phone: 724-545-9774
  • Fax: 724-543-2945
Mailing address:
  • Phone: 724-679-4192
  • Fax: 724-482-1162

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberMD-028840-E
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number42361
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: