Provider Demographics
NPI:1982689121
Name:SELINE, PETER C (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:C
Last Name:SELINE
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 1:428 COUNTY LINE ROAD
Mailing Address - Street 2:
Mailing Address - City:WESTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43082
Mailing Address - Country:US
Mailing Address - Phone:614-847-4100
Mailing Address - Fax:614-430-1601
Practice Address - Street 1:428 COUNTY LINE ROAD
Practice Address - Street 2:
Practice Address - City:WESTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:43082
Practice Address - Country:US
Practice Address - Phone:614-847-4100
Practice Address - Fax:614-430-1601
Is Sole Proprietor?:No
Enumeration Date:2005-12-09
Last Update Date:2020-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35077832207N00000X, 207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000309770OtherANTHEM
OHP00095225OtherRR MEDICARE
OH2192676Medicaid
OH4021363Medicare ID - Type Unspecified
OH2192676Medicaid