1083680128 NPI number — MARY-ELISE 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 1083680128 NPI number — MARY-ELISE SMITH MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SMITH
Provider First Name:
MARY-ELISE
Provider Middle Name:
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:
MANUELL
Provider Other First Name:
MARY-ELISE
Provider Other Middle Name:
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:
1083680128
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/08/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 40
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTHBRIDGE
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01550-0040
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
508-909-7799
Provider Business Mailing Address Fax Number:
508-764-2432

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10 NORTH MAIN STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHARLTON
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01507
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
508-248-1770
Provider Business Practice Location Address Fax Number:
208-248-1769
Provider Enumeration Date:
02/28/2006

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:  82206 , 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)