1063404218 NPI number — LORI S SMETANA MD

Table of content: LORI S SMETANA MD (NPI 1063404218)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063404218 NPI number — LORI S SMETANA MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SMETANA
Provider First Name:
LORI
Provider Middle Name:
S
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:
SAYERS
Provider Other First Name:
LORI
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.D.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1063404218
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/14/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
601 W 5TH AVE
Provider Second Line Business Mailing Address:
SUITE #301
Provider Business Mailing Address City Name:
SPOKANE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
99204-2714
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-455-8866
Provider Business Mailing Address Fax Number:
509-838-3411

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
601 W 5TH AVE
Provider Second Line Business Practice Location Address:
SUITE #301
Provider Business Practice Location Address City Name:
SPOKANE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99204-2714
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-455-8866
Provider Business Practice Location Address Fax Number:
509-838-3411
Provider Enumeration Date:
08/15/2005

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: 174400000X , with the licence number:  MD00033714 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207V00000X , with the licence number: MD00033714 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: SM3651 . This is a "ASURIS" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 8192668 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: A007 . This is a "TRIWEST" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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