Provider Demographics
NPI:1174583173
Name:SMITH, PAUL GORDON (MD)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:GORDON
Last Name:SMITH
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:5333 MCAULEY DRIVE
Mailing Address - Street 2:SUITE 4003
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48197-1099
Mailing Address - Country:US
Mailing Address - Phone:734-712-3470
Mailing Address - Fax:734-712-2935
Practice Address - Street 1:5333 MCAULEY DRIVE
Practice Address - Street 2:SUITE 4003
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48197-1099
Practice Address - Country:US
Practice Address - Phone:734-712-3470
Practice Address - Fax:734-712-2935
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2011-02-09
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI4301040968207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4261954-10Medicaid
MIB45171Medicare UPIN
MI4261954-10Medicaid