Basic Information
| Provider Information | |||||||||
| NPI: | 1417920463 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | ANDRE' | ||||||||
| MiddleName: | BLAIR | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4416 BLACKBERRY LN | ||||||||
| Address2: | |||||||||
| City: | LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 489171633 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5177759799 | ||||||||
| FaxNumber: | 8774885507 | ||||||||
| Practice Location | |||||||||
| Address1: | 4416 BLACKBERRY LN | ||||||||
| Address2: | |||||||||
| City: | LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 489171633 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5177759799 | ||||||||
| FaxNumber: | 8774885507 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/09/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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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 | 207Q00000X | 4301056626 | MI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0330434 | 01 | MI | BCBS | OTHER | 4324357 | 05 | MI | MEDICAID |