MEDICARE: KELLY M SMITH B.S., C.B.I.S. EXP

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	225400000X	Rehabilitation Practitioner	1018	VA
2	225400000X	Rehabilitation Practitioner	1018	MI

General Provider Information

NPI Number	:	1780958769
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY M SMITH B.S., C.B.I.S. EXP

Provider Business Mailing Address
First Line	:	11415 LAUDERDALE CT
Second Line	:
City	:	PINCKNEY
State	:	MI
Zip	:	48169-9535
Country	:	US
Telephone Number	:	734-878-2919
Fax Number	:

Provider Business Practice Location Address
First Line	:	2880 RENFREW ST.
Second Line	:
City	:	ANN ARBOR
State	:	MI
Zip	:	48105-1454
Country	:	US
Telephone Number	:	734-649-6749
Fax Number	:

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

Provider Enumeration Date	:	03/08/2012
Last Update Date	:	03/08/2012

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