Provider Demographics
NPI:1972348563
Name:SMITH, MITCHEL
Entity type:Individual
Prefix:
First Name:MITCHEL
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:406 SCHOCK RD
Mailing Address - Street 2:
Mailing Address - City:HARBOR BEACH
Mailing Address - State:MI
Mailing Address - Zip Code:48441-9703
Mailing Address - Country:US
Mailing Address - Phone:989-712-0202
Mailing Address - Fax:
Practice Address - Street 1:5301 MCAULEY DR STE 100
Practice Address - Street 2:
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48197-1051
Practice Address - Country:US
Practice Address - Phone:810-494-6830
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-26
Last Update Date:2024-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant