Provider Demographics
NPI:1174542781
Name:SMITH, EDWARD F (MD)
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:F
Last Name:SMITH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1140 N. STATE STREET
Mailing Address - Street 2:
Mailing Address - City:ST. IGNACE
Mailing Address - State:MI
Mailing Address - Zip Code:49781
Mailing Address - Country:US
Mailing Address - Phone:906-643-0405
Mailing Address - Fax:906-643-1553
Practice Address - Street 1:1140 N. STATE STREET
Practice Address - Street 2:
Practice Address - City:ST. IGNACE
Practice Address - State:MI
Practice Address - Zip Code:49781
Practice Address - Country:US
Practice Address - Phone:906-643-0405
Practice Address - Fax:906-643-1553
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2016-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301046523174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4432292Medicaid
MIN56640002Medicare ID - Type Unspecified
MID91329Medicare UPIN