Provider Demographics
NPI:1417004904
Name:SMITH, THOMAS GREGORY (DC)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:GREGORY
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 1:2630 GORNO ST
Mailing Address - Street 2:
Mailing Address - City:TRENTON
Mailing Address - State:MI
Mailing Address - Zip Code:48183-2543
Mailing Address - Country:US
Mailing Address - Phone:586-443-5000
Mailing Address - Fax:
Practice Address - Street 1:30521 SCHOENHERR RD STE 106
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48088-3161
Practice Address - Country:US
Practice Address - Phone:586-443-5000
Practice Address - Fax:586-443-5002
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-05
Last Update Date:2023-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301005117111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI141702240Medicaid
MI141702240Medicaid
0H25054Medicare PIN