Provider Demographics
NPI:1023196458
Name:JEFFREY SMITH, MD PC
Entity Type:Organization
Organization Name:JEFFREY SMITH, MD PC
Other - Org Name:GREAT LAKES SURGICAL ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:F
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:989-463-6699
Mailing Address - Street 1:315 E WARWICK DR
Mailing Address - Street 2:#3
Mailing Address - City:ALMA
Mailing Address - State:MI
Mailing Address - Zip Code:48801-1083
Mailing Address - Country:US
Mailing Address - Phone:989-463-6699
Mailing Address - Fax:989-466-2574
Practice Address - Street 1:315 E WARWICK DR
Practice Address - Street 2:#3
Practice Address - City:ALMA
Practice Address - State:MI
Practice Address - Zip Code:48801-1083
Practice Address - Country:US
Practice Address - Phone:989-463-6699
Practice Address - Fax:989-466-2574
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-02
Last Update Date:2021-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301052770174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0N38380Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER