1700901048 NPI number — CHRISTOPHER T SELVAGE, MD, INC.

Table of content: MS. ROBERTA ANN JACKSON L.M.T (NPI 1457502346)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700901048 NPI number — CHRISTOPHER T SELVAGE, MD, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHRISTOPHER T SELVAGE, MD, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1700901048
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/31/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
16946 BURBANK BLVD
Provider Second Line Business Mailing Address:
106
Provider Business Mailing Address City Name:
ENCINO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91316-1870
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
818-990-0179
Provider Business Mailing Address Fax Number:
818-990-0814

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
16946 BURBANK BLVD
Provider Second Line Business Practice Location Address:
106
Provider Business Practice Location Address City Name:
ENCINO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91316-1869
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-990-0179
Provider Business Practice Location Address Fax Number:
818-990-0814
Provider Enumeration Date:
03/19/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SELVAGE
Authorized Official First Name:
CHRISTOPHER
Authorized Official Middle Name:
T
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
818-761-7498

Provider Taxonomy Codes

  • Taxonomy code: 2084P0800X , with the licence number:  A30587 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00A305870 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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