Provider Demographics
NPI:1336362532
Name:ANDREW J SMITH JR MD MEMORIAL GROUP
Entity Type:Organization
Organization Name:ANDREW J SMITH JR MD MEMORIAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:DR
Authorized Official - First Name:J
Authorized Official - Middle Name:GWENDOLYN
Authorized Official - Last Name:GORDON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-424-8888
Mailing Address - Street 1:23077 GREENFIELD RD
Mailing Address - Street 2:STE 200
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-3709
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:23077 GREENFIELD RD
Practice Address - Street 2:STE 200
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-3709
Practice Address - Country:US
Practice Address - Phone:248-424-8888
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-10
Last Update Date:2009-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174400000X
MIJG023085174400000X
MIEC066609174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI451303110Medicaid
MI450374110Medicaid
MIH05380Medicare UPIN
MI450374110Medicaid
MION15220Medicare ID - Type Unspecified