Provider Demographics
NPI:1447538590
Name:SAMUEL, SELYNE (MD)
Entity type:Individual
Prefix:DR
First Name:SELYNE
Middle Name:
Last Name:SAMUEL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3170 KETTERING BLVD
Mailing Address - Street 2:BUILDING B 3RD FLOOR
Mailing Address - City:MOMRAINE
Mailing Address - State:OH
Mailing Address - Zip Code:45439-1924
Mailing Address - Country:US
Mailing Address - Phone:937-991-3188
Mailing Address - Fax:937-223-9811
Practice Address - Street 1:2300 MIAMI VALLEY DR STE 350
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:45459-1294
Practice Address - Country:US
Practice Address - Phone:937-424-2469
Practice Address - Fax:937-424-2479
Is Sole Proprietor?:No
Enumeration Date:2011-07-22
Last Update Date:2021-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-128714208600000X
OH35.1287142086X0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical Oncology
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2551671OtherPARTNERS PHYSICIAN GROUP MEDICAID GROUP #
OH0167456Medicaid
OH1841239274OtherPARTNERS PHYSICIAN GROUP TYPE 2 NPI #
OH9338635OtherPARTNERS PHYSICIAN GROUP MEDICARE GROUP #
OHH476300Medicare PIN