Provider Demographics
NPI:1093792186
Name:SMITH, STACY LYNN (MD)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:LYNN
Last Name:SMITH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37595 7 MILE RD
Mailing Address - Street 2:SUITE 230
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48152-1003
Mailing Address - Country:US
Mailing Address - Phone:734-432-7581
Mailing Address - Fax:
Practice Address - Street 1:37595 7 MILE RD
Practice Address - Street 2:SUITE 330
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48152-1003
Practice Address - Country:US
Practice Address - Phone:734-542-6115
Practice Address - Fax:734-542-6116
Is Sole Proprietor?:No
Enumeration Date:2005-12-29
Last Update Date:2011-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301055133207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP00276787OtherRAILROAD PTAN
MI4742802Medicaid
MI700E012300OtherBCBSM GROUP NUMBER
MI4742802Medicaid
MI700E012300OtherBCBSM GROUP NUMBER