MEDICARE: SELVARAJ MUTHUSAMY M.D.,

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	207ZP0102X	Anatomic Pathology & Clinical Pathology Physician	2014016506	MO

General Provider Information

NPI Number	:	1407260938
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SELVARAJ MUTHUSAMY M.D.,

Provider Business Mailing Address
First Line	:	1325 S GRAND BLVD
Second Line	:	ROOM 436
City	:	SAINT LOUIS
State	:	MO
Zip	:	63104-1018
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1325 S GRAND BLVD
Second Line	:	ROOM 436
City	:	SAINT LOUIS
State	:	MO
Zip	:	63104-1018
Country	:	US
Telephone Number	:	314-577-8694
Fax Number	:

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

Provider Enumeration Date	:	06/12/2014
Last Update Date	:	01/22/2018

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