Healthcare Provider Details

I. General information

NPI: 1023373503
Provider Name (Legal Business Name): LAURA JEAN SMYLIE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2012
Last Update Date: 07/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4201 SAINT ANTOINE ST 6G UHC
DETROIT MI
48201-2153
US

IV. Provider business mailing address

4201 SAINT ANTOINE ST 6G UHC
DETROIT MI
48201-2153
US

V. Phone/Fax

Practice location:
  • Phone: 313-993-2529
  • Fax: 313-993-7703
Mailing address:
  • Phone: 313-993-2529
  • Fax: 313-993-7703

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number4301101090
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: