Healthcare Provider Details

I. General information

NPI: 1306209549
Provider Name (Legal Business Name): MICHAEL SMITH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2016
Last Update Date: 07/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1021 BANDANA BLVD E STE 100
SAINT PAUL MN
55108
US

IV. Provider business mailing address

2925 CHICAGO AVE
MINNEAPOLIS MN
55407-1321
US

V. Phone/Fax

Practice location:
  • Phone: 651-241-9700
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number65782
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: