1306998323 NPI number — DRS STEVEN AND BRENDA SMOKE OD PC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306998323 NPI number — DRS STEVEN AND BRENDA SMOKE OD PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DRS STEVEN AND BRENDA SMOKE OD PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
SMOKE FAMILY VISION CENTER
Provider Other Organization Name Type Code:
3
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:
1306998323
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/24/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 506
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DOWAGIAC
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49047-0506
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
269-782-7141
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
105 PENNSYLVANIA AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DOWAGIAC
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49047-1748
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
269-782-7141
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/18/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SMOKE
Authorized Official First Name:
BRENDA
Authorized Official Middle Name:
D
Authorized Official Title or Position:
VICE PRESIDENT
Authorized Official Telephone Number:
269-782-7141

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  04901003315 , 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: 900A400020 . This is a "BCBS GROUP PIN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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