Provider Demographics
NPI:1306071824
Name:DWIVEDI, SAMVID A (DO)
Entity type:Individual
Prefix:DR
First Name:SAMVID
Middle Name:A
Last Name:DWIVEDI
Suffix:
Gender:M
Credentials:DO
Other - Prefix:DR
Other - First Name:SAMVID
Other - Middle Name:
Other - Last Name:DWIVEDI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DO
Mailing Address - Street 1:2799 W. GRAND BLVD
Mailing Address - Street 2:HENRY FORD HOSPITAL, DEPT OF ANESTHESIOLOGY
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48101-2608
Mailing Address - Country:US
Mailing Address - Phone:313-704-8434
Mailing Address - Fax:
Practice Address - Street 1:2799 W. GRAND AVENUE
Practice Address - Street 2:HENRY FORD HOSPITAL
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48101-2608
Practice Address - Country:US
Practice Address - Phone:313-916-2600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-28
Last Update Date:2017-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101018259207LP2900X, 207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI382791823OtherEIN