Basic Information
| Provider Information | |||||||||
| NPI: | 1447538590 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SAMUEL | ||||||||
| FirstName: | SELYNE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3170 KETTERING BLVD | ||||||||
| Address2: | BUILDING B 3RD FLOOR | ||||||||
| City: | MOMRAINE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454391924 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9379913188 | ||||||||
| FaxNumber: | 9372239811 | ||||||||
| Practice Location | |||||||||
| Address1: | 2300 MIAMI VALLEY DR STE 350 | ||||||||
| Address2: | |||||||||
| City: | CENTERVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454591294 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9374242469 | ||||||||
| FaxNumber: | 9374242479 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/22/2011 | ||||||||
| LastUpdateDate: | 01/19/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 35-128714 | OH | N | Allopathic & Osteopathic Physicians | Surgery | 2086X0206X | 35.128714 | OH | Y | Allopathic & Osteopathic Physicians | Surgery | Surgical Oncology |
ID Information
| ID | Type | State | Issuer | Description | 2551671 | 01 | OH | PARTNERS PHYSICIAN GROUP MEDICAID GROUP # | OTHER | 0167456 | 05 | OH | MEDICAID | 1841239274 | 01 | OH | PARTNERS PHYSICIAN GROUP TYPE 2 NPI # | OTHER | 9338635 | 01 | OH | PARTNERS PHYSICIAN GROUP MEDICARE GROUP # | OTHER |