Sam Dercon, MD

Primary specialty

Emergency Medicine PhysicianTaxonomy code 207P00000X

License

4351048209 Issued in MI

Practice address

2799 W Grand Blvd
Detroit, MI 48202-2608

Phone

(313) 916-1553

NPI assigned

Apr 1, 2021

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Medicare fee-for-service enrollment

Enrolled in CA

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: Yes

Green means eligible to order or refer.

Enrollment records 1

Specialty

Emergency Medicine

Education

Other, 2021

Medicare assignment

Accepts the Medicare-approved amount as payment in full

Group practices

Pacific Redwood Medical Group IncGroup PAC ID 5496652703, 58 clinicians

Practice addresses (Care Compare)

Hospital & facility affiliations

• Adventist Health Ukiah Valley Hospital, Ukiah, CA, CCN 050301
• Adventist Health Clearlake Hospital, Clearlake, CA, CCN 051317

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Medicine

Practice roles

Locations

Interoperability endpoints

• Direct secure messaging: sdercon724199@direct.hfhs.org

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Pacific Redwood Medical Group Inc

  • Emergency Medicine Physician
  • Ukiah, CA
  • NPI 1033103676
  Medicare reassignment Care Compare group NPD

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

• Adventist Health Clearlake Hospital Inc.

  • Critical Access Hospital
  • Clearlake, CA
  • NPI 1124018031
  Care Compare affiliation
• Ukiah Adventist Hospital

  • General Acute Care Hospital
  • Ukiah, CA
  • NPI 1235120676
  Care Compare affiliation

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1617235200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1636329600000",
    "number": "1831777663",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2799 W GRAND BLVD",
            "city": "DETROIT",
            "state": "MI",
            "postal_code": "482022689",
            "telephone_number": "313-461-9533"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2799 W GRAND BLVD",
            "city": "DETROIT",
            "state": "MI",
            "postal_code": "482022608",
            "telephone_number": "313-916-1553"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "DERCON",
        "first_name": "SAM",
        "credential": "MD",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2021-04-01",
        "last_updated": "2021-11-08",
        "certification_date": "2021-11-08",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "390200000X",
            "taxonomy_group": "",
            "desc": "Student in an Organized Health Care Education/Training Program",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207P00000X",
            "taxonomy_group": "",
            "desc": "Emergency Medicine",
            "state": "MI",
            "license": "4351048209",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Alexandra Deporre
• Gunter Deppe, MD
• Abigail Christine Deppen, MS, CGC
• Andrew Deppner
• Talal M Derani, M.D.
• Aimee H Dereczyk, MD
• Amy Dereczyk, PA-C
• Darlene Caryn Dereczyk, ACNP-BC
• David Dennis Dereczyk, PA-C
• Michael Derevensky, MD

• Emergency Medicine Physician in Detroit, MI
• Providers in Detroit, MI by specialty
• Emergency Medicine Physician in Michigan

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 8, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.