Healthcare Provider Details

I. General information

NPI: 1396731055
Provider Name (Legal Business Name): MR. MARK L SMITH
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 09/27/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 S MAIN ST
THREE RIVERS MI
49093-1624
US

IV. Provider business mailing address

210 S MAIN ST
THREE RIVERS MI
49093-1624
US

V. Phone/Fax

Practice location:
  • Phone: 269-273-5000
  • Fax: 269-273-8019
Mailing address:
  • Phone: 269-273-5000
  • Fax: 269-273-8019

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number6801069861
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: