Provider Demographics
NPI:1003979261
Name:SMITH, MICHAEL LOUIS (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:LOUIS
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 1:833 CHESTNUT ST STE 520
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-4430
Mailing Address - Country:US
Mailing Address - Phone:609-677-7003
Mailing Address - Fax:
Practice Address - Street 1:645 MADISON AVE FL 34
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10022-1010
Practice Address - Country:US
Practice Address - Phone:888-636-7840
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2021-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY244016207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02945820Medicaid
NY49C131Medicare PIN