Basic Information
| Provider Information | |||||||||
| NPI: | 1669613220 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RODEN-SMITH | ||||||||
| FirstName: | KELVIN | ||||||||
| MiddleName: | DEWAYNE | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1640 FORT ST | ||||||||
| Address2: | SUITE D ATTN DENISE | ||||||||
| City: | TRENTON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481832040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7343913057 | ||||||||
| FaxNumber: | 7343913052 | ||||||||
| Practice Location | |||||||||
| Address1: | 2333 BIDDLE AVE | ||||||||
| Address2: | |||||||||
| City: | WYANDOTTE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481924668 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7342466000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/11/2009 | ||||||||
| LastUpdateDate: | 02/22/2017 | ||||||||
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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 | 363L00000X | 4704226230 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LA2100X | 4704226230 | MI | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
ID Information
| ID | Type | State | Issuer | Description | PENDING | 01 | BLUE CROSS | OTHER |