Provider Demographics
NPI:1417920463
Name:SMITH, ANDRE' BLAIR (MD)
Entity Type:Individual
Prefix:DR
First Name:ANDRE'
Middle Name:BLAIR
Last Name:SMITH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4416 BLACKBERRY LN
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48917-1633
Mailing Address - Country:US
Mailing Address - Phone:517-775-9799
Mailing Address - Fax:877-488-5507
Practice Address - Street 1:4416 BLACKBERRY LN
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48917-1633
Practice Address - Country:US
Practice Address - Phone:517-775-9799
Practice Address - Fax:877-488-5507
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-09
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301056626207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0330434OtherBCBS
MI4324357Medicaid
MIG60966Medicare UPIN
MI0330434OtherBCBS