Provider Demographics
NPI:1669523650
Name:DAVID J. SMITH MD PC
Entity type:Organization
Organization Name:DAVID J. SMITH MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:J
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:517-627-2181
Mailing Address - Street 1:1035 CHARLEVOIX DR STE 100
Mailing Address - Street 2:
Mailing Address - City:GRAND LEDGE
Mailing Address - State:MI
Mailing Address - Zip Code:48837-2223
Mailing Address - Country:US
Mailing Address - Phone:517-627-2181
Mailing Address - Fax:517-622-1242
Practice Address - Street 1:1035 CHARLEVOIX DR STE 100
Practice Address - Street 2:
Practice Address - City:GRAND LEDGE
Practice Address - State:MI
Practice Address - Zip Code:48837-2223
Practice Address - Country:US
Practice Address - Phone:517-627-2181
Practice Address - Fax:517-622-1242
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-16
Last Update Date:2017-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401007475101YP2500X
MI4704208405363LF0000X
MIDS030055207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI080B360240OtherBCBSM GROUP NUMBER
C1769OtherMEDICARE RAILROAD
MI080B360240OtherBCBSM GROUP NUMBER