Provider Demographics
NPI:1740464361
Name:PRIEM, SHAWN MICHAEL (DO)
Entity type:Individual
Prefix:DR
First Name:SHAWN
Middle Name:MICHAEL
Last Name:PRIEM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3131 NEWMARK DR
Mailing Address - Street 2:
Mailing Address - City:MIAMISBURG
Mailing Address - State:OH
Mailing Address - Zip Code:45342-5448
Mailing Address - Country:US
Mailing Address - Phone:937-438-8910
Mailing Address - Fax:
Practice Address - Street 1:3535 SOUTHERN BLVD
Practice Address - Street 2:
Practice Address - City:KETTERING
Practice Address - State:OH
Practice Address - Zip Code:45429
Practice Address - Country:US
Practice Address - Phone:937-395-8166
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-18
Last Update Date:2019-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34-00-9155207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2859821Medicaid
KY7100113550Medicaid
IN200983040Medicaid
IN200983040Medicaid
OH4266483Medicare PIN