Healthcare Provider Details

I. General information

NPI: 1306071824
Provider Name (Legal Business Name): SAMVID A DWIVEDI D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: SAMVID DWIVEDI DO

II. Dates (important events)

Enumeration Date: 05/28/2009
Last Update Date: 10/25/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2799 W. GRAND AVENUE HENRY FORD HOSPITAL
DETROIT MI
48101-2608
US

IV. Provider business mailing address

2799 W. GRAND BLVD HENRY FORD HOSPITAL, DEPT OF ANESTHESIOLOGY
DETROIT MI
48101-2608
US

V. Phone/Fax

Practice location:
  • Phone: 313-916-2600
  • Fax:
Mailing address:
  • Phone: 313-704-8434
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number5101018259
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number5101018259
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: