Provider Demographics
NPI:1134116270
Name:SELBST, RICHARD G (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:G
Last Name:SELBST
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 1:354 MERRIMACK ST
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:MA
Mailing Address - Zip Code:01843-1754
Mailing Address - Country:US
Mailing Address - Phone:978-687-2321
Mailing Address - Fax:978-685-7265
Practice Address - Street 1:354 MERRIMACK ST
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:MA
Practice Address - Zip Code:01843-1754
Practice Address - Country:US
Practice Address - Phone:978-687-2321
Practice Address - Fax:978-685-7265
Is Sole Proprietor?:No
Enumeration Date:2005-10-04
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA496772084N0400X
NH66062084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0167703Medicaid
MA05-00255OtherEVERCARE
MA05-00022OtherUHC
MA11731OtherHPHC
MA4460335OtherAETNA
MA715264OtherTHP
MA0003751OtherNHP
MAD02067OtherBCBS
NH00000166Medicaid
NH0102760Y0MA01OtherANTHEM
MA1127308-001OtherCIGNA
MA23597OtherFCHP
MA4460335OtherAETNA
MAD02067Medicare ID - Type UnspecifiedMEDICARE
NH00000166Medicaid