Provider Demographics
NPI:1518994565
Name:DEREMER, SHAWN MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:SHAWN
Middle Name:MICHAEL
Last Name:DEREMER
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:P.O. BOX 2817
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208
Mailing Address - Country:US
Mailing Address - Phone:954-545-0337
Mailing Address - Fax:954-545-3497
Practice Address - Street 1:10150 SE 32ND AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97222-6516
Practice Address - Country:US
Practice Address - Phone:503-513-8300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD22534207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR288087Medicaid
ORP00256935OtherRAILROAD MEDICARE
ORP00256935OtherRAILROAD MEDICARE