Basic Information
Provider Information | |||||||||
NPI: | 1295171734 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SMITH | ||||||||
FirstName: | ANDREW | ||||||||
MiddleName: | GERRITT | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 850 N HARRISON ST | ||||||||
Address2: |   | ||||||||
City: | WARSAW | ||||||||
State: | IN | ||||||||
PostalCode: | 465803199 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8003425653 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2799 W GRAND BLVD | ||||||||
Address2: |   | ||||||||
City: | DETROIT | ||||||||
State: | MI | ||||||||
PostalCode: | 482022608 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8006536568 | ||||||||
FaxNumber: | 3138761305 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/10/2013 | ||||||||
LastUpdateDate: | 11/01/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 11/01/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 64289 | TN | N |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0800X | EMC0001208 | MI | N |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0800X | 29231 | MS | N |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0800X | E15105 | AR | N |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0804X | 27002 | WV | N |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry | 2084P0804X | 01081179A | IN | N |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry | 2084P0800X | 01081179A | IN | Y |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
No ID Information.