Healthcare Provider Details

I. General information

NPI: 1366498131
Provider Name (Legal Business Name): LISA KAY SMITH MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LISA SMITH

II. Dates (important events)

Enumeration Date: 05/25/2006
Last Update Date: 07/14/2025
Certification Date: 07/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 SHELDON AVE SE STE 100
GRAND RAPIDS MI
49503-4224
US

IV. Provider business mailing address

100 MICHIGAN ST NE # MC845
GRAND RAPIDS MI
49503-2560
US

V. Phone/Fax

Practice location:
  • Phone: 616-391-6120
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4301080102
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number4301080102
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: