Healthcare Provider Details

I. General information

NPI: 1063426880
Provider Name (Legal Business Name): SELENA B PETERS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2006
Last Update Date: 06/04/2024
Certification Date: 06/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 SKOKIE BLVD STE 300
NORTHBROOK IL
60062-1601
US

IV. Provider business mailing address

40 SKOKIE BLVD STE 300
NORTHBROOK IL
60062-1601
US

V. Phone/Fax

Practice location:
  • Phone: 866-729-1012
  • Fax: 847-996-2147
Mailing address:
  • Phone: 866-729-1012
  • Fax: 847-996-2147

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number54751
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code207LA0401X
TaxonomyAddiction Medicine (Anesthesiology) Physician
License Number36166538
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number36166538
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: