Provider Demographics
NPI:1962409961
Name:SMITH, KENNETH E (MD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:E
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 1:2689 SOLUTION CENTER
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-2308
Mailing Address - Country:US
Mailing Address - Phone:586-329-1880
Mailing Address - Fax:586-231-0055
Practice Address - Street 1:30795 23 MILE RD STE 201
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:MI
Practice Address - Zip Code:48047-5721
Practice Address - Country:US
Practice Address - Phone:586-421-1600
Practice Address - Fax:586-421-2002
Is Sole Proprietor?:No
Enumeration Date:2005-07-05
Last Update Date:2021-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301059550207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI700E04360OtherBLUE CROSS BLUE SHIELDS OF MICHIGAN
MI3152688Medicaid
MIOM33200009009Medicare ID - Type Unspecified
MI3152688Medicaid
MIMI8102002Medicare PIN