Provider Demographics
NPI:1447381561
Name:DAHMER, GREGORY S (ORTHOTIST, ATC)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:S
Last Name:DAHMER
Suffix:
Gender:M
Credentials:ORTHOTIST, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:943 MAPLE DR
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26505-2812
Mailing Address - Country:US
Mailing Address - Phone:304-285-3734
Mailing Address - Fax:304-285-3738
Practice Address - Street 1:943 MAPLE DR
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26505-2812
Practice Address - Country:US
Practice Address - Phone:304-285-3734
Practice Address - Fax:304-285-3738
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2013-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVC26333222Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810008417Medicaid