Healthcare Provider Details

I. General information

NPI: 1699795781
Provider Name (Legal Business Name): CHANNING MARSHALL SMITH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2006
Last Update Date: 03/06/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

214 N. WEST AVE
JACKSON MI
49201-1903
US

IV. Provider business mailing address

214 N. WEST AVE
JACKSON MI
49201-1903
US

V. Phone/Fax

Practice location:
  • Phone: 517-784-9189
  • Fax: 517-784-9657
Mailing address:
  • Phone: 517-784-9189
  • Fax: 517-784-9657

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4301077287
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: