Provider Demographics
NPI:1194148379
Name:MICHAEL J. SMULLEN, MD
Entity type:Organization
Organization Name:MICHAEL J. SMULLEN, MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLO PRACTITIONER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:SMULLEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:920-499-0696
Mailing Address - Street 1:1239 W MASON ST
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54303-2047
Mailing Address - Country:US
Mailing Address - Phone:920-499-0696
Mailing Address - Fax:920-499-0697
Practice Address - Street 1:1239 W MASON ST
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54303-2047
Practice Address - Country:US
Practice Address - Phone:920-499-0696
Practice Address - Fax:920-499-0697
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-24
Last Update Date:2014-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30979400Medicaid
WIB56727Medicare UPIN