Healthcare Provider Details

I. General information

NPI: 1538312228
Provider Name (Legal Business Name): PIAM SHANEHSAZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/28/2008
Last Update Date: 05/05/2023
Certification Date: 05/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3535 SOUTHERN BLVD
KETTERING OH
45429-1221
US

IV. Provider business mailing address

1 PRESTIGE PL STE 550
MIAMISBURG OH
45342-6115
US

V. Phone/Fax

Practice location:
  • Phone: 937-395-6665
  • Fax: 937-395-6668
Mailing address:
  • Phone: 937-766-2131
  • Fax: 937-522-8068

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number44158
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number35.096488
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number35.096488
License Number StateOH
# 4
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number44158
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: