Healthcare Provider Details

I. General information

NPI: 1316334998
Provider Name (Legal Business Name): SELORM TAKYI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/21/2015
Last Update Date: 08/27/2020
Certification Date: 08/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 LINCOLN DR W STE E
MARLTON NJ
08053-1534
US

IV. Provider business mailing address

197 RIDGEDALE AVE STE 210
CEDAR KNOLLS NJ
07927-2111
US

V. Phone/Fax

Practice location:
  • Phone: 856-983-9001
  • Fax: 856-983-9011
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number25MA10560400
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: