Provider Demographics
NPI:1881684983
Name:SMITH, MICHAEL KENNETH (DO)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:KENNETH
Last Name:SMITH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:17375 HALL RD
Mailing Address - Street 2:
Mailing Address - City:MACOMB TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48044-4060
Mailing Address - Country:US
Mailing Address - Phone:586-228-0550
Mailing Address - Fax:586-228-8125
Practice Address - Street 1:17375 HALL RD
Practice Address - Street 2:
Practice Address - City:MACOMB TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48044-4060
Practice Address - Country:US
Practice Address - Phone:586-228-0550
Practice Address - Fax:586-228-8125
Is Sole Proprietor?:No
Enumeration Date:2005-10-28
Last Update Date:2008-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101007651208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1886059Medicaid
MIA76221Medicare UPIN
MI0N87470Medicare PIN