Provider Demographics
NPI:1871559146
Name:CONVERY, SEAN ROBERT (MD)
Entity type:Individual
Prefix:
First Name:SEAN
Middle Name:ROBERT
Last Name:CONVERY
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 1:2350 MIAMI VALLEY DR
Mailing Address - Street 2:STE 320
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45459-4778
Mailing Address - Country:US
Mailing Address - Phone:937-312-1661
Mailing Address - Fax:937-312-1701
Practice Address - Street 1:2350 MIAMI VALLEY DR
Practice Address - Street 2:STE 320
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45459-4778
Practice Address - Country:US
Practice Address - Phone:937-312-1661
Practice Address - Fax:937-312-1701
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2013-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.047658207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0527826Medicaid
OH0527826Medicaid
C00514534Medicare ID - Type Unspecified
OHH066530Medicare PIN