Basic Information
| Provider Information | |||||||||
| NPI: | 1477089357 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | RYAN | ||||||||
| MiddleName: | MICHAEL | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 27450 SCHOENHERR RD STE 400 | ||||||||
| Address2: | |||||||||
| City: | WARREN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480886684 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5865827550 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 12000 E 12 MILE RD | ||||||||
| Address2: | |||||||||
| City: | WARREN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480933570 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5865735000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2017 | ||||||||
| LastUpdateDate: | 08/06/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207Q00000X | 5101023366 | MI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.