Healthcare Provider Details

I. General information

NPI: 1750484879
Provider Name (Legal Business Name): MARK WILLIAM SMITH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/06/2006
Last Update Date: 07/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14734 PARK AVE
CHARLEVOIX MI
49720-1927
US

IV. Provider business mailing address

14734 PARK AVE
CHARLEVOIX MI
49720-1927
US

V. Phone/Fax

Practice location:
  • Phone: 231-547-6554
  • Fax: 231-547-1179
Mailing address:
  • Phone: 231-547-6554
  • Fax: 231-547-1179

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4301076489
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: