Healthcare Provider Details

I. General information

NPI: 1437618345
Provider Name (Legal Business Name): ABIGAIL SUSAN SMITH MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/19/2019
Last Update Date: 11/06/2023
Certification Date: 11/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 N EAST AVE
JACKSON MI
49201-1753
US

IV. Provider business mailing address

205 N EAST AVE
JACKSON MI
49201-1753
US

V. Phone/Fax

Practice location:
  • Phone: 517-205-7836
  • Fax: 517-205-7660
Mailing address:
  • Phone: 517-205-7836
  • Fax: 517-205-7660

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number4301508819
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: