Provider Demographics
NPI:1548619943
Name:SMALLEY, KEVIN ANDREW (DO)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:ANDREW
Last Name:SMALLEY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 776982
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6982
Mailing Address - Country:US
Mailing Address - Phone:800-494-5797
Mailing Address - Fax:
Practice Address - Street 1:1445 SHELDON RD
Practice Address - Street 2:STE 3000
Practice Address - City:GRAND HAVEN
Practice Address - State:MI
Practice Address - Zip Code:49417
Practice Address - Country:US
Practice Address - Phone:616-296-1500
Practice Address - Fax:616-296-1502
Is Sole Proprietor?:No
Enumeration Date:2016-06-07
Last Update Date:2024-11-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5101022547207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1548619943Medicaid