1851613475 NPI number — MR. BARRY CHILDS SMITH PHYSICIANS ASSISTANT

Table of content: MR. BARRY CHILDS SMITH PHYSICIANS ASSISTANT (NPI 1851613475)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1851613475 NPI number — MR. BARRY CHILDS SMITH PHYSICIANS ASSISTANT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SMITH
Provider First Name:
BARRY
Provider Middle Name:
CHILDS
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
PHYSICIANS ASSISTANT
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:
1851613475
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/10/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
751 E 9 MILE RD
Provider Second Line Business Mailing Address:
STE 100
Provider Business Mailing Address City Name:
FERNDALE
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48220-1990
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-336-2850
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
30500 VAN DYKE AVE STE 203
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WARREN
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48093-2109
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-480-9066
Provider Business Practice Location Address Fax Number:
248-480-9062
Provider Enumeration Date:
02/23/2010

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: 363A00000X , with the licence number:  5601001288 , 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)





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