Healthcare Provider Details

I. General information

NPI: 1558533083
Provider Name (Legal Business Name): SELVON F ST. CLAIR MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2008
Last Update Date: 08/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 MEDICAL DR SUITE A
LIMA OH
45804-4031
US

IV. Provider business mailing address

801 MEDICAL DR SUITE A
LIMA OH
45804-4031
US

V. Phone/Fax

Practice location:
  • Phone: 419-222-6622
  • Fax: 419-224-0015
Mailing address:
  • Phone: 419-222-6622
  • Fax: 419-224-0015

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number#35-088609
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License Number35.088609
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: