Provider Demographics
NPI:1720002017
Name:WEISS, MYRA J (MD)
Entity Type:Individual
Prefix:
First Name:MYRA
Middle Name:J
Last Name:WEISS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1695 W 12 MILE ROAD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:BERKLEY
Mailing Address - State:MI
Mailing Address - Zip Code:48072-2100
Mailing Address - Country:US
Mailing Address - Phone:248-548-9090
Mailing Address - Fax:248-548-8462
Practice Address - Street 1:1695 W 12 MILE ROAD
Practice Address - Street 2:SUITE 200
Practice Address - City:BERKLEY
Practice Address - State:MI
Practice Address - Zip Code:48072-2100
Practice Address - Country:US
Practice Address - Phone:248-548-9090
Practice Address - Fax:248-548-8462
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301036736207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2899338Medicaid
MIB45329Medicare UPIN