1053393066 NPI number — MELISSA GARRISON SMITH APRN

Table of content: MELISSA GARRISON SMITH APRN (NPI 1053393066)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053393066 NPI number — MELISSA GARRISON SMITH APRN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SMITH
Provider First Name:
MELISSA
Provider Middle Name:
GARRISON
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
APRN
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GARRISON
Provider Other First Name:
MELISSA
Provider Other Middle Name:
SUE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
APRN
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1053393066
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/29/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
38135 MARKET SQ
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ZEPHYRHILLS
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33542-7505
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
352-567-0188
Provider Business Mailing Address Fax Number:
813-355-5101

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7229 US HIGHWAY 301 S
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RIVERVIEW
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33578-4346
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
813-677-8418
Provider Business Practice Location Address Fax Number:
813-355-5906
Provider Enumeration Date:
11/16/2005

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: 363L00000X , with the licence number:  4704194300 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: 9270004 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 110747200 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 700G560080 . This is a "BCBS GROUP-THREE RIVERS HEALTH" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: JQ238 . This is a "MEDICARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 4741645 10 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: AZ946Z . This is a "MEDICARE PTAN" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: Y0JU7 . This is a "BCBS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 110747200 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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