Basic Information
| Provider Information | |||||||||
| NPI: | 1174752547 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | KRISTY | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 28800 RYAN RD | ||||||||
| Address2: | SUITE 120 | ||||||||
| City: | WARREN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480924272 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5865582860 | ||||||||
| FaxNumber: | 5865584624 | ||||||||
| Practice Location | |||||||||
| Address1: | 28800 RYAN RD | ||||||||
| Address2: | SUITE 120 | ||||||||
| City: | WARREN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480924272 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5865582860 | ||||||||
| FaxNumber: | 5865584624 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2009 | ||||||||
| LastUpdateDate: | 05/05/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 4301095192 | MI | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207PS0010X | 4301095192 | MI | Y | Allopathic & Osteopathic Physicians | Emergency Medicine | Sports Medicine |
No ID Information.