Provider Demographics
NPI:1013959113
Name:SMITH, ELIZABETH C (MD)
Entity Type:Individual
Prefix:DR
First Name:ELIZABETH
Middle Name:C
Last Name:SMITH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5777 WEST MAPLE RD.
Mailing Address - Street 2:SUITE 170
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48322
Mailing Address - Country:US
Mailing Address - Phone:248-855-0077
Mailing Address - Fax:248-855-0042
Practice Address - Street 1:5777 WEST MAPLE RD.
Practice Address - Street 2:SUITE 170
Practice Address - City:WEST BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48322
Practice Address - Country:US
Practice Address - Phone:248-855-0077
Practice Address - Fax:248-855-0042
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-12
Last Update Date:2012-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010674872084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
11289153OtherCAQH
H12163Medicare UPIN
0P31350Medicare ID - Type Unspecified