1578712956 NPI number — STACEY ANN MILLER-SMITH MD

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 1578712956 NPI number — STACEY ANN MILLER-SMITH MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MILLER-SMITH
Provider First Name:
STACEY
Provider Middle Name:
ANN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MILLER
Provider Other First Name:
STACEY
Provider Other Middle Name:
ANN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1578712956
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/30/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
325 PRINCETON AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PRINCETON
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08540-1617
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
609-924-8131
Provider Business Mailing Address Fax Number:
609-924-8532

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
325 PRINCETON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PRINCETON
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08540-1617
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
609-924-8131
Provider Business Practice Location Address Fax Number:
609-924-8532
Provider Enumeration Date:
09/10/2008

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: 208100000X , with the licence number:  25MA08436300 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 144202ACD . This is a "MEDICARE PTAN" identifier . This identifiers is of the category "OTHER".




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