Provider Demographics
NPI:1245605872
Name:SMAK, EDWARD ADAM (RN)
Entity Type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:ADAM
Last Name:SMAK
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2766 WEST 11 MILE ROAD
Mailing Address - Street 2:SUITE #2
Mailing Address - City:BERKLEY
Mailing Address - State:MI
Mailing Address - Zip Code:48072
Mailing Address - Country:US
Mailing Address - Phone:248-542-2424
Mailing Address - Fax:248-542-5621
Practice Address - Street 1:1515 GREENWOOD AVE.
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49203
Practice Address - Country:US
Practice Address - Phone:517-787-5710
Practice Address - Fax:517-787-9855
Is Sole Proprietor?:No
Enumeration Date:2015-12-08
Last Update Date:2015-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704165138163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse