Provider Demographics
NPI:1841298775
Name:MARIA I. SELIVERSTOV, MD INC.
Entity type:Organization
Organization Name:MARIA I. SELIVERSTOV, MD INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:I
Authorized Official - Last Name:SELIVERSTOV
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-986-9232
Mailing Address - Street 1:4835 VAN NUYS BLVD
Mailing Address - Street 2:#104
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91403
Mailing Address - Country:US
Mailing Address - Phone:818-986-9232
Mailing Address - Fax:818-986-9716
Practice Address - Street 1:4835 VAN NUYS BLVD
Practice Address - Street 2:#104
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91403
Practice Address - Country:US
Practice Address - Phone:818-986-9232
Practice Address - Fax:818-986-9716
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-13
Last Update Date:2007-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA0669382084P2900X, 2084P0805X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric PsychiatryGroup - Multi-Specialty
No2084P2900XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPain MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A669380Medicaid
CAA66938Medicare PIN
G87917Medicare UPIN