=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780732941
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHRIS T SELVAGE M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/06/2007
-----------------------------------------------------
Last Update Date | 07/31/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 16946 BURBANK BLVD SUITE 106
-----------------------------------------------------
City | ENCINO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91316-1869
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-990-0179
-----------------------------------------------------
Fax | 818-990-0814
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 16946 BURBANK BLVD SUITE 106
-----------------------------------------------------
City | ENCINO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91316-1869
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-990-0179
-----------------------------------------------------
Fax | 818-990-0814
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | A30587
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------