Provider Demographics
NPI:1225321813
Name:SELVARAJ, PRABAHARAN
Entity Type:Individual
Prefix:
First Name:PRABAHARAN
Middle Name:
Last Name:SELVARAJ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4782 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:CASS CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48726-1049
Mailing Address - Country:US
Mailing Address - Phone:989-872-2174
Mailing Address - Fax:989-872-2204
Practice Address - Street 1:4782 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:CASS CITY
Practice Address - State:MI
Practice Address - Zip Code:48726-1049
Practice Address - Country:US
Practice Address - Phone:989-872-2174
Practice Address - Fax:989-872-2204
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-16
Last Update Date:2013-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501015285225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist