Provider Demographics
NPI:1437299237
Name:DETWEILER, SAMUEL DEAN (MD)
Entity Type:Individual
Prefix:MR
First Name:SAMUEL
Middle Name:DEAN
Last Name:DETWEILER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:427 GUY PARK AVE - PRIMARY & SPECIALTY CARE DEPT.
Mailing Address - Street 2:ST. MARY'S HOSPITAL AT AMSTERDAM
Mailing Address - City:AMSTERDAM
Mailing Address - State:NY
Mailing Address - Zip Code:12010
Mailing Address - Country:US
Mailing Address - Phone:518-841-7430
Mailing Address - Fax:518-841-7121
Practice Address - Street 1:331 BRIDGE ST
Practice Address - Street 2:ST. MARY'S HOSPITAL, NORTHVILLE FAMILY HEALTH CENTER
Practice Address - City:NORTHVILLE
Practice Address - State:NY
Practice Address - Zip Code:12134
Practice Address - Country:US
Practice Address - Phone:518-863-4200
Practice Address - Fax:518-863-4787
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-08
Last Update Date:2010-09-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY157873207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY000419006006OtherBS PROVIDER NUMBER
NY77787OtherMVP
NY040426006943OtherFIDELIS
NY10000485OtherCDPHP
NYD76905Medicare UPIN
NY77787OtherMVP