Provider Demographics
NPI:1689748725
Name:SMITH, ERIC G (MD)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:G
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 1:1035 CHARLEVOIX DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:GRAND LEDGE
Mailing Address - State:MI
Mailing Address - Zip Code:48837-2223
Mailing Address - Country:US
Mailing Address - Phone:517-627-2181
Mailing Address - Fax:
Practice Address - Street 1:1035 CHARLEVOIX DR
Practice Address - Street 2:SUITE 100
Practice Address - City:GRAND LEDGE
Practice Address - State:MI
Practice Address - Zip Code:48837-2223
Practice Address - Country:US
Practice Address - Phone:517-627-2181
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2014-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIES076441207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP260036FOtherBCN PIN
MI0802310081OtherBCBS INDIVIDUAL PIN
P00103325OtherMEDICARE RAILROAD
MI0802310081OtherBCBS INDIVIDUAL PIN
MIH88946Medicare UPIN