MEDICARE: MS. KRISTINE KAY SMITH MS, ATC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2255A2300X	Athletic Trainer		IL

General Provider Information

NPI Number	:	1033194154
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. KRISTINE KAY SMITH MS, ATC

Provider Business Mailing Address
First Line	:	4926 HEATHER DR
Second Line	:	APT 112
City	:	DEARBORN
State	:	MI
Zip	:	48126-4134
Country	:	US
Telephone Number	:	847-636-9215
Fax Number	:

Provider Business Practice Location Address
First Line	:	261 MACK AVE
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48201-2417
Country	:	US
Telephone Number	:	313-745-1160
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/12/2005
Last Update Date	:	07/16/2007

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