Provider Demographics
NPI:1457429987
Name:SMITH, STEPHEN TIMOTHY (MD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:TIMOTHY
Last Name:SMITH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 WARREN CT
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:MI
Mailing Address - Zip Code:48009-3302
Mailing Address - Country:US
Mailing Address - Phone:248-495-8984
Mailing Address - Fax:
Practice Address - Street 1:2799 W GRAND BLVD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202-2608
Practice Address - Country:US
Practice Address - Phone:800-653-6568
Practice Address - Fax:313-876-1305
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2023-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-124708207RC0000X
MI4301044365207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
060H264410OtherBLUE CROSS-BLUE CROSS
MI143671610Medicaid
SS044365OtherCHAMPUS-CHAMPUS
SS044365OtherCOMMERCIAL-COMMERCIAL NUMBER
SS044365OtherCHAMPUS-CHAMPUS
B48177Medicare UPIN