Healthcare Provider Details

I. General information

NPI: 1447386214
Provider Name (Legal Business Name): VIJAYALAKSHMI SELVARAJ MD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/26/2007
Last Update Date: 08/22/2020
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:
Mailing address:
  • Phone: 724-789-9950
  • Fax:

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: MS. DEBORA K SAFRANEK
Title or Position: OFFICE MANAGER
Credential:
Phone: 724-789-9957