Basic Information
| Provider Information | |||||||||
| NPI: | 1184663726 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | KYLE | ||||||||
| MiddleName: | G | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 888 WEST BIG BEAVER RD #1450 | ||||||||
| Address2: | |||||||||
| City: | TROY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48084 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2482448644 | ||||||||
| FaxNumber: | 2482441330 | ||||||||
| Practice Location | |||||||||
| Address1: | 888 W BIG BEAVER RD | ||||||||
| Address2: | 1450 | ||||||||
| City: | TROY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480844736 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5867543060 | ||||||||
| FaxNumber: | 5866270027 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2006 | ||||||||
| LastUpdateDate: | 06/02/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 5101009975 | MI | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 4738004 11 | 05 | MI | MEDICAID |