Healthcare Provider Details

I. General information

NPI: 1265015754
Provider Name (Legal Business Name): SPENCER LEVI SMITH RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/03/2021
Last Update Date: 10/09/2023
Certification Date: 10/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1215 E MICHIGAN AVE
LANSING MI
48912-1896
US

IV. Provider business mailing address

9295 JASON RD
LAINGSBURG MI
48848-9216
US

V. Phone/Fax

Practice location:
  • Phone: 517-364-1000
  • Fax:
Mailing address:
  • Phone: 989-370-2164
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number4704294008
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: