1720067606 NPI number — DR. DAVID WEAVER DO

Table of content: DR. DAVID WEAVER DO (NPI 1720067606)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720067606 NPI number — DR. DAVID WEAVER DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WEAVER
Provider First Name:
DAVID
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1720067606
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/22/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
29150 BUCKINGHAM ST
Provider Second Line Business Mailing Address:
SUITE 6
Provider Business Mailing Address City Name:
LIVONIA
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48154-7502
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
734-207-9999
Provider Business Mailing Address Fax Number:
734-838-0052

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7300 N CANTON CENTER RD
Provider Second Line Business Practice Location Address:
EMERGENCY MEDICINE DEPARTMENT
Provider Business Practice Location Address City Name:
CANTON
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48187-1579
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
734-454-8002
Provider Business Practice Location Address Fax Number:
734-454-2733
Provider Enumeration Date:
01/10/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207P00000X , with the licence number:  5101008321 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207P00000X , with the licence number: 0102202236 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207P00000X , with the licence number: OS014356 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: 5101008321 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1720067606 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 11293324 . This is a "CAQH" identifier . This identifiers is of the category "OTHER".