Healthcare Provider Details

I. General information

NPI: 1770627051
Provider Name (Legal Business Name): CHAD D SMITH PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/19/2007
Last Update Date: 02/10/2020
Certification Date: 02/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1316 MERCY DR
MUSKEGON MI
49444-1891
US

IV. Provider business mailing address

370 N 120TH AVE
HOLLAND MI
49424-2196
US

V. Phone/Fax

Practice location:
  • Phone: 231-739-9461
  • Fax: 231-733-8131
Mailing address:
  • Phone: 616-396-5855
  • Fax: 616-396-5720

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601005752
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: