Provider Demographics
NPI:1174752547
Name:SMITH, KRISTY MARIE (MD)
Entity type:Individual
Prefix:DR
First Name:KRISTY
Middle Name:MARIE
Last Name:SMITH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:28800 RYAN RD
Mailing Address - Street 2:SUITE 120
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48092-4272
Mailing Address - Country:US
Mailing Address - Phone:586-558-2860
Mailing Address - Fax:586-558-4624
Practice Address - Street 1:28800 RYAN RD
Practice Address - Street 2:SUITE 120
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48092-4272
Practice Address - Country:US
Practice Address - Phone:586-558-2860
Practice Address - Fax:586-558-4624
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-07
Last Update Date:2024-10-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301095192207P00000X, 207PS0010X
IN01093465A207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PS0010XAllopathic & Osteopathic PhysiciansEmergency MedicineSports Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine