Basic Information
| Provider Information | |||||||||
| NPI: | 1770675290 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | DEBORAH | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 14705 W UPRIGHT ST | ||||||||
| Address2: | |||||||||
| City: | CHARLEVOIX | ||||||||
| State: | MI | ||||||||
| PostalCode: | 497201949 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2315476519 | ||||||||
| FaxNumber: | 2315475404 | ||||||||
| Practice Location | |||||||||
| Address1: | 14705 W UPRIGHT ST | ||||||||
| Address2: | |||||||||
| City: | CHARLEVOIX | ||||||||
| State: | MI | ||||||||
| PostalCode: | 497201949 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2315476519 | ||||||||
| FaxNumber: | 2315475404 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/29/2006 | ||||||||
| LastUpdateDate: | 12/30/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 12/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 4301079953 | MI | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | 4301079953 | MI | N | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 4301079953 | 01 | MI | BC LICENSE NUMBER | OTHER | 4847573 | 05 | MI | MEDICAID | DS079953 | 01 | MI | BLUE SHIELD | OTHER | 381459366067 | 01 | MI | COMMUNITY CHOICE PIN# | OTHER |