Basic Information
| Provider Information | |||||||||
| NPI: | 1669764635 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SELVARAJAH | ||||||||
| FirstName: | ANDREW | ||||||||
| MiddleName: | NIROSHAN | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9977 WOODS DR FL 1 | ||||||||
| Address2: | |||||||||
| City: | SKOKIE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600771057 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2243642273 | ||||||||
| FaxNumber: | 8476638290 | ||||||||
| Practice Location | |||||||||
| Address1: | 635 N FAIRBANKS CT | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606115435 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3124723173 | ||||||||
| FaxNumber: | 3124723176 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2011 | ||||||||
| LastUpdateDate: | 05/03/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 036147132 | IL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0111304 | 05 | OH | MEDICAID | 2047778 | 05 | WA | MEDICAID |