Provider Demographics
NPI:1578529178
Name:SMITH, STANLEY R (MD)
Entity Type:Individual
Prefix:
First Name:STANLEY
Middle Name:R
Last Name:SMITH
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:PO BOX 1108
Mailing Address - Street 2:ATTN: BARB SIMMONS
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48106-1108
Mailing Address - Country:US
Mailing Address - Phone:231-627-5601
Mailing Address - Fax:231-627-1592
Practice Address - Street 1:330 E MITCHELL ST
Practice Address - Street 2:#210
Practice Address - City:PETOSKEY
Practice Address - State:MI
Practice Address - Zip Code:49770-2671
Practice Address - Country:US
Practice Address - Phone:734-677-7400
Practice Address - Fax:734-677-7407
Is Sole Proprietor?:No
Enumeration Date:2006-04-22
Last Update Date:2010-01-28
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI43010308122085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4372499Medicaid
MI0B41005OtherBCBS GROUP PIN
MIM72490014Medicare PIN
B45637Medicare UPIN
MI0M72490Medicare PIN