1134127152 NPI number — DENNIS A SMALLWOOD D.O.

Table of content: DENNIS A SMALLWOOD D.O. (NPI 1134127152)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134127152 NPI number — DENNIS A SMALLWOOD D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SMALLWOOD
Provider First Name:
DENNIS
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
D.O.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1134127152
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/13/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
192 S LAKE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORT SANILAC
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48469-9620
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1184 CLEAVER RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CARO
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48723-1143
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
888-758-5709
Provider Business Practice Location Address Fax Number:
888-490-5454
Provider Enumeration Date:
07/13/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2083P0901X , with the licence number:  DS005982 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 4582075 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4590694 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 01-5-32-1087-5 . This is a "BCBS PIN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 4590685 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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