Healthcare Provider Details

I. General information

NPI: 1477556918
Provider Name (Legal Business Name): MICHAEL ELLSWORTH SMOTHERS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/28/2005
Last Update Date: 07/20/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3003 E LAKE DR S
ELKHART IN
46514-4327
US

IV. Provider business mailing address

3003 E LAKE DR S
ELKHART IN
46514-4327
US

V. Phone/Fax

Practice location:
  • Phone: 574-206-0465
  • Fax: 574-262-5217
Mailing address:
  • Phone: 574-206-0465
  • Fax: 574-262-5217

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01042198
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number01042198
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4301042611
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: