Healthcare Provider Details

I. General information

NPI: 1184932824
Provider Name (Legal Business Name): PAUL SELVADURAI INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/15/2010
Last Update Date: 09/21/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6651 CHIPPEWA ST SUITE 214
SAINT LOUIS MO
63109-2538
US

IV. Provider business mailing address

6651 CHIPPEWA ST SUITE 214
SAINT LOUIS MO
63109-2538
US

V. Phone/Fax

Practice location:
  • Phone: 314-647-5300
  • Fax: 314-647-1996
Mailing address:
  • Phone: 314-647-5300
  • Fax: 314-647-1996

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA59661504
License Number StateZZ

VIII. Authorized Official

Name: MRS. DARLENE BYRD
Title or Position: OFFICE MANAGER
Credential:
Phone: 314-647-5300