Provider Demographics
NPI:1700909702
Name:DEEM, SAMUEL GRAY (DO)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:GRAY
Last Name:DEEM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:3100 MACCORKLE AVE SE STE 602
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25304
Mailing Address - Country:US
Mailing Address - Phone:304-388-5280
Mailing Address - Fax:304-388-5291
Practice Address - Street 1:3100 MACCORKLE AVE SE
Practice Address - Street 2:SUITE 602
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25304-1223
Practice Address - Country:US
Practice Address - Phone:304-388-5120
Practice Address - Fax:304-388-5125
Is Sole Proprietor?:No
Enumeration Date:2007-04-06
Last Update Date:2015-12-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WV2176208800000X, 208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVP01087428OtherRAILROAD MEDICARE
WV3810010649Medicaid
WV3810010649Medicaid