Provider Demographics
NPI:1669764635
Name:SELVARAJAH, ANDREW NIROSHAN (MD)
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:NIROSHAN
Last Name:SELVARAJAH
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 1:9977 WOODS DR FL 1
Mailing Address - Street 2:
Mailing Address - City:SKOKIE
Mailing Address - State:IL
Mailing Address - Zip Code:60077-1057
Mailing Address - Country:US
Mailing Address - Phone:224-364-2273
Mailing Address - Fax:847-663-8290
Practice Address - Street 1:635 N FAIRBANKS CT
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-5435
Practice Address - Country:US
Practice Address - Phone:312-472-3173
Practice Address - Fax:312-472-3176
Is Sole Proprietor?:No
Enumeration Date:2011-05-10
Last Update Date:2021-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036147132207Q00000X
IL036.147132207Q00000X
OH35.124300207Q00000X
WAMD60574506207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0111304Medicaid
WA2047778Medicaid
OHH438740Medicare PIN
OH0111304Medicaid