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General NPI Number Information
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NPI Number | 1053545913
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Entity Type | Individual
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Provider Name | PRADEEP KUMAR SELVARAJ M.D
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Gender | Male
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Dates
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Enumeration Date | 05/07/2009
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Last Update Date | 07/25/2017
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Provider Practice Location Address
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Address Line | 451 BANK ST
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City | WOODVILLE
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State | MS
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Zip | 39669-6000
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Country | US
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Telephone | 601-888-3421
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Fax | 601-888-3685
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Provider Business Mailing Address
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Address Line | 178 HIGHWAY 24 E
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City | CENTREVILLE
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State | MS
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Zip | 39631-4171
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Country | US
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Telephone | 601-890-0500
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | 22109
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License Number State | MS
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