1093825630 NPI number — BRIAN K SMITH MD

Table of content: BRIAN K SMITH MD (NPI 1093825630)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093825630 NPI number — BRIAN K SMITH MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SMITH
Provider First Name:
BRIAN
Provider Middle Name:
K
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:
1093825630
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/15/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3340 NORTH CENTER ST
Provider Second Line Business Mailing Address:
#800
Provider Business Mailing Address City Name:
LEHI
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84043-7406
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-990-1911
Provider Business Mailing Address Fax Number:
801-990-1912

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4401 HARRISON BOULEVARD
Provider Second Line Business Practice Location Address:
MCKAY DEE HOSPITAL
Provider Business Practice Location Address City Name:
OGDEN
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84403
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-507-5248
Provider Business Practice Location Address Fax Number:
801-733-5618
Provider Enumeration Date:
08/30/2006

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: 207L00000X , with the licence number:  30-82898-1205 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 116283700 , issued by the state of ( WY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 870545614SMT . This is a "EDUCATORS MUTUAL" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 1502954 . This is a "UMWA" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 526920 . This is a "DESERET MUTUAL" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 57972 . This is a "PEHP" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 704 . This is a "HEALTHY U" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 805975100 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 822165 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: QM0000075886 . This is a "ALTIUS" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 100501277 , issued by the state of ( NV ) . This identifiers is of the category "MEDICAID".
  • Identifier: 107008901101 . This is a "IHC" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 2090168 . This is a "UNITED" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 30828981200001 . This is a "BCBS" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: TPRA07387 . This is a "MOLINA" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".




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