Healthcare Provider Details

I. General information

NPI: 1548256399
Provider Name (Legal Business Name): NIRANJAN M SELVARAJAH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/26/2005
Last Update Date: 10/26/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1729 BURRSTONE ROAD SLOCUM DICKSON MEDICAL GROUP
NEW HARTFORD NY
13413-6680
US

IV. Provider business mailing address

1729 BURRSTONE ROAD SLOCUM DICKSON MEDICAL GROUP
NEW HARTFORD NY
13413-6680
US

V. Phone/Fax

Practice location:
  • Phone: 315-798-1700
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number238340
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number238340
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: