Provider Demographics
NPI:1093822595
Name:SELVAM, M PANNIR (MD)
Entity Type:Individual
Prefix:
First Name:M
Middle Name:PANNIR
Last Name:SELVAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:946 W 79TH STREET
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60620
Mailing Address - Country:US
Mailing Address - Phone:773-723-8501
Mailing Address - Fax:773-723-3578
Practice Address - Street 1:946 W 79TH STREET
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60620
Practice Address - Country:US
Practice Address - Phone:773-723-8501
Practice Address - Fax:773-723-3578
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2017-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036065767207Q00000X
IL36065767207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036065767Medicaid
C48689Medicare UPIN