Provider Demographics
NPI:1851800874
Name:SMITH, MICHAEL
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:833 CHESTNUT ST STE 520
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-4430
Mailing Address - Country:US
Mailing Address - Phone:609-677-7003
Mailing Address - Fax:
Practice Address - Street 1:7975 LAKE UNDERHILL RD STE 330
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32822-8210
Practice Address - Country:US
Practice Address - Phone:844-407-4070
Practice Address - Fax:407-743-3050
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-21
Last Update Date:2022-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9110665363A00000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant