Healthcare Provider Details

I. General information

NPI: 1407436603
Provider Name (Legal Business Name): SAMMY E DIA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2021
Last Update Date: 07/28/2025
Certification Date: 07/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35 MICHIGAN ST NE STE 5301
GRAND RAPIDS MI
49503-2530
US

IV. Provider business mailing address

100 MICHIGAN ST NE # MC845
GRAND RAPIDS MI
49503-2560
US

V. Phone/Fax

Practice location:
  • Phone: 616-391-8842
  • Fax: 616-391-2978
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4351048146
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code2080H0002X
TaxonomyPediatric Hospice and Palliative Medicine Physician
License Number4351048146
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: