Basic Information
| Provider Information | |||||||||
| NPI: | 1952335028 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VIEDER | ||||||||
| FirstName: | SANFORD | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6530 BRISTOL DR | ||||||||
| Address2: | |||||||||
| City: | WEST BLOOMFIELD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483223240 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2489312274 | ||||||||
| FaxNumber: | 2486619088 | ||||||||
| Practice Location | |||||||||
| Address1: | 28050 GRAND RIVER AVENUE | ||||||||
| Address2: | ER DEPARTMENT | ||||||||
| City: | FARMINGTON HILLS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48336 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2484718808 | ||||||||
| FaxNumber: | 2486157415 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2006 | ||||||||
| LastUpdateDate: | 12/02/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207PE0004X | SV010234 | MI | N | Allopathic & Osteopathic Physicians | Emergency Medicine | Emergency Medical Services | 207P00000X | 5101010234 | MI | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 114575660 | 05 | MI | MEDICAID |