Provider Demographics
NPI:1255533014
Name:SMITH, NICHOLAS DAVID (MSPT)
Entity type:Individual
Prefix:MR
First Name:NICHOLAS
Middle Name:DAVID
Last Name:SMITH
Suffix:
Gender:M
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:538 ELEANOR ST NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49505-4103
Mailing Address - Country:US
Mailing Address - Phone:616-540-9767
Mailing Address - Fax:
Practice Address - Street 1:1525 E BELTLINE AVE NE STE 101
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-4598
Practice Address - Country:US
Practice Address - Phone:616-363-7879
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI55010112282251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3343400Medicaid
MI3343400Medicaid