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NPI Code Detail

MEDICARE: SAMUEL GRAY DEEM DO

MEDICARE: SAMUEL GRAY DEEM DO
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1208800000XUrology Physician2176WV

Medicare Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1P01087428OTHERWVRAILROAD MEDICARE

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
2MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1700909702
Entity Type Code : Individual
Provider Name (Legal Business Name) : SAMUEL GRAY DEEM DO
Provider Business Mailing Address
First Line : 3100 MACCORKLE AVE SE STE 602
Second Line :
City : CHARLESTON
State : WV
Zip : 25304-1231
Country : US
Telephone Number : 304-388-5280
Fax Number : 304-388-5291
Provider Business Practice Location Address
First Line : 3100 MACCORKLE AVE SE
Second Line : SUITE 602
City : CHARLESTON
State : WV
Zip : 25304-1223
Country : US
Telephone Number : 304-388-5120
Fax Number : 304-388-5125
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 04/06/2007
Last Update Date : 12/01/2025

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Directions to “ SAMUEL GRAY DEEM DO” Practice Location

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