MEDICARE: DR. RAMASAMY SELVARAJ MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207P00000X	Emergency Medicine Physician	J0894	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	8G9181	OTHER	TX	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1295792612
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RAMASAMY SELVARAJ MD

Provider Business Mailing Address
First Line	:	PO BOX 3407
Second Line	:
City	:	WICHITA FALLS
State	:	TX
Zip	:	76301-0407
Country	:	US
Telephone Number	:	940-763-1200
Fax Number	:	940-763-1207

Provider Business Practice Location Address
First Line	:	1600 11TH ST
Second Line	:
City	:	WICHITA FALLS
State	:	TX
Zip	:	76301-4300
Country	:	US
Telephone Number	:	940-764-7000
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/28/2006
Last Update Date	:	10/26/2007

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