Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 2086S0129X | Vascular Surgeon | 35-084264 | OH |
Y | 2086S0129X | Vascular Surgeon | 4301069776 | MI |
NPI | 1033191994 |
---|---|
Provider Name | Mitchell Ross Weaver |
First Address | Detroit, MI 48202-2608 |
Second Address | Detroit, MI 48202-2608 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 16/11/2005 |
Last Update Date | 01/03/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
000000329893 | ANTHEM BC/BS (01) | OH |
2497463 | (05) | OH |
7030574 | AETNA PROVIDER ID# (01) | |
I08676 | (02) | OH |