Healthcare Provider Details

I. General information

NPI: 1538577531
Provider Name (Legal Business Name): MARCUS SMITHSON MBA, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/23/2014
Last Update Date: 01/23/2023
Certification Date: 01/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7349 CLEARVIEW DR
CALEDONIA MI
49316-9309
US

IV. Provider business mailing address

7349 CLEARVIEW DR
CALEDONIA MI
49316-9309
US

V. Phone/Fax

Practice location:
  • Phone: 906-367-0062
  • Fax:
Mailing address:
  • Phone: 906-367-0062
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2601001202
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: