Provider Demographics
NPI:1003830530
Name:SMITH, MICHAEL WARREN (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:WARREN
Last Name:SMITH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:6115 PARK SOUTH DR STE 100
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28210-3281
Mailing Address - Country:US
Mailing Address - Phone:704-554-8787
Mailing Address - Fax:704-554-8774
Practice Address - Street 1:6115 PARK SOUTH DR STE 100
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28210-3281
Practice Address - Country:US
Practice Address - Phone:704-554-8787
Practice Address - Fax:704-554-8774
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2023-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200300709207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC891341GMedicaid
NC1003830530Medicaid
SCN00701Medicaid
NC1003830530Medicaid
SCN00701Medicaid
NC2021067Medicare PIN