Provider Demographics
NPI:1477512168
Name:SMALLEY, MARK (DO)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:SMALLEY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:3950 HOLLYWOOD RD
Mailing Address - Street 2:SUITE 270
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MI
Mailing Address - Zip Code:49085-9159
Mailing Address - Country:US
Mailing Address - Phone:269-982-7840
Mailing Address - Fax:269-982-7843
Practice Address - Street 1:3950 HOLLYWOOD RD
Practice Address - Street 2:SUITE 270
Practice Address - City:SAINT JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085-9159
Practice Address - Country:US
Practice Address - Phone:269-982-7840
Practice Address - Fax:269-982-7843
Is Sole Proprietor?:No
Enumeration Date:2006-03-21
Last Update Date:2019-05-07
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MIMS007105207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0A110280OtherBCBS
MI110203217OtherRAIL ROAD MEDICARE
MI0M94300Medicare PIN
MI110203217OtherRAIL ROAD MEDICARE
MIE26417Medicare UPIN