Individual
MITCHELL ROSS WEAVER
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
2799 W GRAND BLVD, DETROIT, MI 48202-2608
(313) 916-3156
(313) 916-3023
Mailing address
2799 W GRAND BLVD, DETROIT, MI 48202-2608
(313) 916-3156
(313) 916-3023
Taxonomy
Speciality
Code
Description
License number
State
2086S0129X
Vascular Surgery Physician
35-084264
OH
2086S0129X
Vascular Surgery Physician
Primary
4301069776
MI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000000329893
ANTHEM BC/BS
OH
05
—
2497463
—
OH
01
—
7030574
AETNA PROVIDER ID#
—
Enumeration date
11/16/2005
Last updated
03/01/2021
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