Provider Demographics
NPI:1386809796
Name:STANICH, PETER P (MD)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:P
Last Name:STANICH
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 ACKERMAN RD STE 2120
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43202-1559
Mailing Address - Country:US
Mailing Address - Phone:614-293-6255
Mailing Address - Fax:614-293-8518
Practice Address - Street 1:410 W 10TH AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43210-1240
Practice Address - Country:US
Practice Address - Phone:614-293-6255
Practice Address - Fax:614-293-8518
Is Sole Proprietor?:No
Enumeration Date:2008-07-24
Last Update Date:2025-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN52085207R00000X
OH35097099207RG0100X, 207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNENROLLEDMedicaid
MNENROLLEDMedicaid