Provider Demographics
NPI:1225142615
Name:SMITH, GALEN DAVID (PA-C)
Entity Type:Individual
Prefix:
First Name:GALEN
Middle Name:DAVID
Last Name:SMITH
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:81 S RINGLE RD
Mailing Address - Street 2:
Mailing Address - City:FAIRGROVE
Mailing Address - State:MI
Mailing Address - Zip Code:48733-9525
Mailing Address - Country:US
Mailing Address - Phone:989-843-5135
Mailing Address - Fax:989-843-5121
Practice Address - Street 1:2112 E OHMER RD
Practice Address - Street 2:
Practice Address - City:MAYVILLE
Practice Address - State:MI
Practice Address - Zip Code:48744-9501
Practice Address - Country:US
Practice Address - Phone:989-843-5135
Practice Address - Fax:989-843-5121
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601003431363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5601003431OtherSTATE LICENCE
MIP17072Medicare UPIN