1750794798 NPI number — MS. DOMINIQUE MARIELLE SMITH BA-HIS

Table of content: MS. DOMINIQUE MARIELLE SMITH BA-HIS (NPI 1750794798)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750794798 NPI number — MS. DOMINIQUE MARIELLE SMITH BA-HIS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SMITH
Provider First Name:
DOMINIQUE
Provider Middle Name:
MARIELLE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
BA-HIS
Provider Gender Code:
F

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:
1750794798
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/13/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
18800 EUREKA RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTHGATE
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48195-3166
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
734-285-3770
Provider Business Mailing Address Fax Number:
734-285-3781

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
30550 STEPHENSON HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MADISON HEIGHTS
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48071-1611
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-837-6298
Provider Business Practice Location Address Fax Number:
248-837-6299
Provider Enumeration Date:
06/07/2014

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: 237700000X , with the licence number:  3501004958 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 237700000X , with the licence number: 3501004948 , 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: 15013663 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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