Provider Demographics
NPI:1811224561
Name:SELVARAJAN, SANTOSH KUMAR (MD)
Entity Type:Individual
Prefix:DR
First Name:SANTOSH
Middle Name:KUMAR
Last Name:SELVARAJAN
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 1:111 S 11TH ST
Mailing Address - Street 2:STE 3390
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-4824
Mailing Address - Country:US
Mailing Address - Phone:215-955-6226
Mailing Address - Fax:215-923-1562
Practice Address - Street 1:111 S 11TH ST
Practice Address - Street 2:STE 3390
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-4824
Practice Address - Country:US
Practice Address - Phone:215-955-6226
Practice Address - Fax:215-923-1562
Is Sole Proprietor?:No
Enumeration Date:2009-11-17
Last Update Date:2013-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2421542085N0700X
PAMD4489522085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102845367Medicaid
NJ0361976Medicaid
NJ0361976Medicaid