Healthcare Provider Details

I. General information

NPI: 1275646648
Provider Name (Legal Business Name): PAUL N SELVADURAI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/17/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6651 CHIPPEWA ST STE 214
ST LOUIS MO
63109-2538
US

IV. Provider business mailing address

6651 CHIPPEWA ST STE 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 Code173000000X
TaxonomyLegal Medicine
License NumberR6369
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: