Provider Demographics
NPI:1700901048
Name:CHRISTOPHER T SELVAGE, MD, INC.
Entity Type:Organization
Organization Name:CHRISTOPHER T SELVAGE, MD, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:T
Authorized Official - Last Name:SELVAGE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-761-7498
Mailing Address - Street 1:16946 BURBANK BLVD
Mailing Address - Street 2:106
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91316-1870
Mailing Address - Country:US
Mailing Address - Phone:818-990-0179
Mailing Address - Fax:818-990-0814
Practice Address - Street 1:16946 BURBANK BLVD
Practice Address - Street 2:106
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91316-1869
Practice Address - Country:US
Practice Address - Phone:818-990-0179
Practice Address - Fax:818-990-0814
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-19
Last Update Date:2008-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA305872084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A305870Medicaid
CA00A305870Medicaid