Basic Information
| Provider Information | |||||||||
| NPI: | 1104169697 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 725 UNIVERSITY BLVD | ||||||||
| Address2: | |||||||||
| City: | DAYTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454350001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372457100 | ||||||||
| FaxNumber: | 9372457999 | ||||||||
| Practice Location | |||||||||
| Address1: | 1222 S PATTERSON BLVD | ||||||||
| Address2: | STE 220 | ||||||||
| City: | DAYTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454022684 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372235350 | ||||||||
| FaxNumber: | 9372243112 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/03/2013 | ||||||||
| LastUpdateDate: | 11/20/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/20/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 35.128066 | OH | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0167298 | 05 | OH | MEDICAID |