1720031925 NPI number — PAMELA J SMITH MD

Table of content: PAMELA J SMITH MD (NPI 1720031925)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720031925 NPI number — PAMELA J SMITH MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SMITH
Provider First Name:
PAMELA
Provider Middle Name:
J
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:
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:
1720031925
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/23/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12 GILL ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WOBURN
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01801-1728
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
781-937-4522
Provider Business Mailing Address Fax Number:
781-937-4510

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
25 HIGHLAND AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEWBURYPORT
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01950-3867
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
978-463-1050
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/18/2006

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: 207P00000X , with the licence number:  40008 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207P00000X , with the licence number: 160859 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: J21316 . This is a "BCBS OF MA" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 3198758 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".