MEDICARE: DEVPRAKASH SAMUEL MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084N0400X	Neurology Physician	4301055010	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1307401332	OTHER	MI	BLUE CROSS BLUE SHIELD
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1760579171
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEVPRAKASH SAMUEL MD

Provider Business Mailing Address
First Line	:	3050 KRAFFT RD
Second Line	:
City	:	FORT GRATIOT
State	:	MI
Zip	:	48059-3821
Country	:	US
Telephone Number	:	810-385-7700
Fax Number	:	810-385-7760

Provider Business Practice Location Address
First Line	:	3050 KRAFFT RD
Second Line	:
City	:	FORT GRATIOT
State	:	MI
Zip	:	48059-3821
Country	:	US
Telephone Number	:	810-385-7700
Fax Number	:	810-385-7760

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/06/2006
Last Update Date	:	07/08/2007

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