Basic Information
Provider Information
NPI: 1003005315
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: SMITH
FirstName: ADAM
MiddleName: BRYANT
NamePrefix: DR.
NameSuffix:  
Credential: MD
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 4977 SKYVIEW CT
Address2:  
City: TRAVERSE CITY
State: MI
PostalCode: 496846941
CountryCode: US
TelephoneNumber: 2314216599
FaxNumber: 2314216602
Practice Location
Address1: 4977 SKYVIEW CT
Address2:  
City: TRAVERSE CITY
State: MI
PostalCode: 496846941
CountryCode: US
TelephoneNumber: 2314216599
FaxNumber: 2314216602
Other Information
ProviderEnumerationDate: 10/23/2007
LastUpdateDate: 07/22/2011
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
208600000X$$$$$$$$$MIN Allopathic & Osteopathic PhysiciansSurgery 
2086S0122X036123693ILY Allopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery

No ID Information.


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