Healthcare Provider Details

I. General information

NPI: 1679985311
Provider Name (Legal Business Name): KEIRSTEN E SMITH M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KEIRSTEN DAVIO MD

II. Dates (important events)

Enumeration Date: 05/29/2014
Last Update Date: 02/04/2022
Certification Date: 02/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

145 4TH AVE NE FAMILY PRACTICE/ SPORTS MEDICINE
GLADSTONE MI
49837
US

IV. Provider business mailing address

145 4TH AVE NE FAMILY PRACTICE/ SPORTS MEDICINE
GLADSTONE MI
49837
US

V. Phone/Fax

Practice location:
  • Phone: 906-428-3273
  • Fax: 906-428-1881
Mailing address:
  • Phone: 906-428-3273
  • Fax: 906-428-1881

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD36202
License Number StateAL
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberL4014R
License Number StateAL
# 4
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4301116666
License Number StateMI
# 5
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number430111666
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: