1104961994 NPI number — KENT SMILLIE MD

Table of content: KENT SMILLIE MD (NPI 1104961994)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104961994 NPI number — KENT SMILLIE MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SMILLIE
Provider First Name:
KENT
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:
1104961994
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/10/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
787 37TH ST STE E200
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VERO BEACH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32960-7306
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
772-978-7808
Provider Business Mailing Address Fax Number:
772-978-9320

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
787 37TH ST STE E200
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VERO BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32960-7306
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
772-978-7808
Provider Business Practice Location Address Fax Number:
772-978-9320
Provider Enumeration Date:
02/20/2007

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: 207X00000X , with the licence number:  MD00042627 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207X00000X , with the licence number: 01068319A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207X00000X , with the licence number: 0101249094 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207X00000X , with the licence number: MD20796 , registered in the state of ME ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207X00000X , with the licence number: ME130147 , 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: 200985030 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 247586 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 88545M . This is a "REGENCE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 000000668941 . This is a "ANTHEM PROVIDER NUMBER" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 0176932 . This is a "LABOR & INDUSTRIES" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 8931559 . This is a "CRIME VICTIMS" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 019183400 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8379323 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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