Provider Demographics
NPI:1033191994
Name:WEAVER, MITCHELL ROSS (MD)
Entity Type:Individual
Prefix:
First Name:MITCHELL
Middle Name:ROSS
Last Name:WEAVER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2799 W GRAND BLVD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48202-2608
Mailing Address - Country:US
Mailing Address - Phone:313-916-3156
Mailing Address - Fax:313-916-3023
Practice Address - Street 1:2799 W GRAND BLVD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202-2608
Practice Address - Country:US
Practice Address - Phone:313-916-3156
Practice Address - Fax:313-916-3023
Is Sole Proprietor?:No
Enumeration Date:2005-11-16
Last Update Date:2021-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-0842642086S0129X
MI43010697762086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2497463Medicaid
7030574OtherAETNA PROVIDER ID#
OH000000329893OtherANTHEM BC/BS
OH000000329893OtherANTHEM BC/BS
OHI08676Medicare UPIN
OHP00102210Medicare ID - Type UnspecifiedRAILROAD MEDICARE