Provider Demographics
NPI:1376670430
Name:SMITH, MICHAEL SCOTT (DC)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:SCOTT
Last Name:SMITH
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 151
Mailing Address - Street 2:
Mailing Address - City:DWIGHT
Mailing Address - State:IL
Mailing Address - Zip Code:60420-0151
Mailing Address - Country:US
Mailing Address - Phone:815-584-2225
Mailing Address - Fax:
Practice Address - Street 1:108 S FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:DWIGHT
Practice Address - State:IL
Practice Address - Zip Code:60420-1345
Practice Address - Country:US
Practice Address - Phone:815-584-2225
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-27
Last Update Date:2020-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038-008658111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL03223254OtherBLUE CROSS BLUE SHIELD
551250OtherMEDICARE PTAN
IL03223254OtherBLUE CROSS BLUE SHIELD
36-4379101OtherFEDERAL EIN