1245204890 NPI number — MR. GREGORY A. SMITH FNP

Table of content: MR. GREGORY A. SMITH FNP (NPI 1245204890)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245204890 NPI number — MR. GREGORY A. SMITH FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SMITH
Provider First Name:
GREGORY
Provider Middle Name:
A.
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
FNP
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:
1245204890
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/02/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2955 HARRISON ST
Provider Second Line Business Mailing Address:
SUITE 301
Provider Business Mailing Address City Name:
BEAUMONT
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77702-1154
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
409-923-1650
Provider Business Mailing Address Fax Number:
409-923-1651

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2955 HARRISON ST
Provider Second Line Business Practice Location Address:
SUITE 301
Provider Business Practice Location Address City Name:
BEAUMONT
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77702-1154
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
409-923-1650
Provider Business Practice Location Address Fax Number:
409-923-1651
Provider Enumeration Date:
02/13/2006

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: 363LF0000X , with the licence number:  559394 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 179210302 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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