Healthcare Provider Details

I. General information

NPI: 1003854563
Provider Name (Legal Business Name): VIJAYALAKSHMI SELVARAJ M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/04/2006
Last Update Date: 06/13/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

851 EVANS CITY RD
RENFREW PA
16053-9207
US

IV. Provider business mailing address

851 EVANS CITY RD
RENFREW PA
16053-9207
US

V. Phone/Fax

Practice location:
  • Phone: 724-789-9950
  • Fax: 724-789-9958
Mailing address:
  • Phone: 724-789-9950
  • Fax: 724-789-9958

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD028373E
License Number StateGA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier0015452650004
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: