Provider Demographics
NPI:1114072972
Name:SMITH, KELLY RAE (RDCS, RVT)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:RAE
Last Name:SMITH
Suffix:
Gender:F
Credentials:RDCS, RVT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 S WASHINGTON AVE
Mailing Address - Street 2:ULTRASOUND DEPT
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48601-2551
Mailing Address - Country:US
Mailing Address - Phone:989-907-8229
Mailing Address - Fax:
Practice Address - Street 1:800 S WASHINGTON AVE
Practice Address - Street 2:ULTRASOUND DEPT
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48601-2551
Practice Address - Country:US
Practice Address - Phone:989-907-8229
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI102782471V0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2471V0105XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistVascular Sonography