Basic Information
| Provider Information | |||||||||
| NPI: | 1538189428 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | B | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 700 S 320TH ST | ||||||||
| Address2: | SUITE B | ||||||||
| City: | FEDERAL WAY | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980034691 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2538381520 | ||||||||
| FaxNumber: | 2538384933 | ||||||||
| Practice Location | |||||||||
| Address1: | 700 S 320TH ST | ||||||||
| Address2: | SUITE B | ||||||||
| City: | FEDERAL WAY | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980034691 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2538381520 | ||||||||
| FaxNumber: | 2538384933 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2006 | ||||||||
| LastUpdateDate: | 12/30/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | MD00021374 | WA | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 0650736 | 01 | WA | AETNA MANAGED CARE | OTHER | 1048727 | 05 | WA | MEDICAID | 4078987 | 01 | WA | AETNA PPO | OTHER | SM6887 | 01 | WA | REGENCE | OTHER | 7117773 | 01 | WA | GROUP WA PROVIDER NO | OTHER |