Provider Demographics
NPI:1285696690
Name:SEREQUE, PETER ARNOLD (MD)
Entity type:Individual
Prefix:DR
First Name:PETER
Middle Name:ARNOLD
Last Name:SEREQUE
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 1:248 LAKE FOREST DR
Mailing Address - Street 2:
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29307-3753
Mailing Address - Country:US
Mailing Address - Phone:864-541-4957
Mailing Address - Fax:864-560-6009
Practice Address - Street 1:250 N GROVE MEDICAL PARK DR
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29303-4222
Practice Address - Country:US
Practice Address - Phone:864-560-7002
Practice Address - Fax:864-560-6009
Is Sole Proprietor?:No
Enumeration Date:2006-04-03
Last Update Date:2011-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC07180207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC007180Medicaid
SCD993811804Medicare ID - Type Unspecified
SC007180Medicaid