MEDICARE: KELLY J SMITH NP

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	363L00000X	Nurse Practitioner	4704152480	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1528035078
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY J SMITH NP

Provider Business Mailing Address
First Line	:	200 N PARK ST
Second Line	:
City	:	KALAMAZOO
State	:	MI
Zip	:	49007-3731
Country	:	US
Telephone Number	:	269-382-2500
Fax Number	:	269-373-7478

Provider Business Practice Location Address
First Line	:	200 N PARK ST
Second Line	:	WEST MICHIGAN CANCER CENTER
City	:	KALAMAZOO
State	:	MI
Zip	:	49007-3731
Country	:	US
Telephone Number	:	269-382-2500
Fax Number	:	269-373-7478

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

Provider Enumeration Date	:	03/03/2006
Last Update Date	:	11/17/2020

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