1124118799 NPI number — SAMUEL SMITH MD

Table of content: SAMUEL SMITH MD (NPI 1124118799)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124118799 NPI number — SAMUEL SMITH MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SMITH
Provider First Name:
SAMUEL
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1124118799
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/06/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 251418
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LITTLE ROCK
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72225-1418
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
501-364-1100
Provider Business Mailing Address Fax Number:
501-364-4082

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1 CHILDRENS WAY # 653
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LITTLE ROCK
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72202-3500
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
501-364-1100
Provider Business Practice Location Address Fax Number:
501-364-4082
Provider Enumeration Date:
10/13/2006

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: 2086S0120X , with the licence number:  C-5848 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 55251 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: C5848 . This is a "TRICARE" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 121199001 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 020033263 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 12039000000 . This is a "QUALCHOICE" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".




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