Provider Demographics
NPI:1124540364
Name:SERINA, PETER
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:SERINA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 E ONTARIO ST STE 200
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-3284
Mailing Address - Country:US
Mailing Address - Phone:312-694-7000
Mailing Address - Fax:
Practice Address - Street 1:211 E ONTARIO ST STE 200
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611
Practice Address - Country:US
Practice Address - Phone:312-926-6493
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-10
Last Update Date:2018-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125073355207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL125073355Medicaid