Healthcare Provider Details

I. General information

NPI: 1720481476
Provider Name (Legal Business Name): SAMANTHA REIDT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/08/2014
Last Update Date: 06/27/2021
Certification Date: 06/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4200 WHITEHALL DR STE 130
ANN ARBOR MI
48105
US

IV. Provider business mailing address

14998 MELROSE ST
LIVONIA MI
48154-3572
US

V. Phone/Fax

Practice location:
  • Phone: 734-995-0303
  • Fax:
Mailing address:
  • Phone: 586-554-0117
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number5601007128
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: