Basic Information
| Provider Information | |||||||||
| NPI: | 1144203175 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SMITH | ||||||||
| OtherFirstName: | JEFFREY | ||||||||
| OtherMiddleName: | D | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 11149 SUMMERHILL WAY | ||||||||
| Address2: | |||||||||
| City: | CHARLEVOIX | ||||||||
| State: | MI | ||||||||
| PostalCode: | 497209077 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9785057006 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4170 CEDAR BLUFF DR | ||||||||
| Address2: | |||||||||
| City: | PETOSKEY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 497707627 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2314872230 | ||||||||
| FaxNumber: | 2314876172 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/23/2005 | ||||||||
| LastUpdateDate: | 04/28/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208200000X | 4301059444 | MI | Y | Allopathic & Osteopathic Physicians | Plastic Surgery | 174400000X | 204149 | MA | N | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 1144203175 | 05 | MI | MEDICAID | 3208079 | 05 | MA | MEDICAID |