Provider Demographics
NPI:1669571444
Name:SMITH, ELAINE C (DO)
Entity type:Individual
Prefix:DR
First Name:ELAINE
Middle Name:C
Last Name:SMITH
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 427
Mailing Address - Street 2:
Mailing Address - City:HILLMAN
Mailing Address - State:MI
Mailing Address - Zip Code:49746-0427
Mailing Address - Country:US
Mailing Address - Phone:989-354-2197
Mailing Address - Fax:
Practice Address - Street 1:21258 M 68 HWY
Practice Address - Street 2:
Practice Address - City:ONAWAY
Practice Address - State:MI
Practice Address - Zip Code:49765-9692
Practice Address - Country:US
Practice Address - Phone:989-733-2082
Practice Address - Fax:989-733-8487
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2013-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101013616207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
080Z410300OtherBLUE SHIELD
MI4620407Medicaid
MI4620407Medicaid
MION90680Medicare ID - Type Unspecified