MEDICARE: WAYNE SMITH DO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	5101011102	MI
2	2083X0100X	Occupational Medicine Physician	5101011102	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1205842101
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WAYNE SMITH DO

Provider Business Mailing Address
First Line	:	PO BOX 1847
Second Line	:
City	:	MUSKEGON
State	:	MI
Zip	:	49443-1847
Country	:	US
Telephone Number	:	231-672-4900
Fax Number	:

Provider Business Practice Location Address
First Line	:	3210 EAGLE RUN DR NE STE 100
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49525-7051
Country	:	US
Telephone Number	:	616-279-3725
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/31/2006
Last Update Date	:	11/21/2019

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Directions to “ WAYNE SMITH DO” Practice Location

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