Provider Demographics
NPI:1235110693
Name:PREM, JEFFREY T (MD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:T
Last Name:PREM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6046 WHIPPLE AVE NW STE 203
Mailing Address - Street 2:
Mailing Address - City:NORTH CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44720-7616
Mailing Address - Country:US
Mailing Address - Phone:330-588-8900
Mailing Address - Fax:330-588-8990
Practice Address - Street 1:6046 WHIPPLE AVE NW STE 203
Practice Address - Street 2:
Practice Address - City:NORTH CANTON
Practice Address - State:OH
Practice Address - Zip Code:44720-7616
Practice Address - Country:US
Practice Address - Phone:330-588-8900
Practice Address - Fax:330-588-8990
Is Sole Proprietor?:No
Enumeration Date:2005-11-10
Last Update Date:2020-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35071936P208600000X, 2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2048484Medicaid
OHG76278Medicare UPIN
OH2048484Medicaid