1003011446 NPI number — BAXTER J. SMITH JR., OD, PA

Table of content: (NPI 1003011446)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003011446 NPI number — BAXTER J. SMITH JR., OD, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BAXTER J. SMITH JR., OD, PA
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:
HEALTHDRIVE EYE CARE GROUP
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:
1003011446
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/14/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
100 CROSSING BLVD STE 300
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FRAMINGHAM
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01702-5555
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
888-964-6681
Provider Business Mailing Address Fax Number:
339-686-2561

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5960 FAIRVIEW RD STE 300
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHARLOTTE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28210-0202
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
888-964-6681
Provider Business Practice Location Address Fax Number:
888-662-0859
Provider Enumeration Date:
06/17/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SMITH
Authorized Official First Name:
BAXTER
Authorized Official Middle Name:
J.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
857-255-0486

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  858 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 8909846 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com