1285608703 NPI number — MS. TARA SHANNON SMITH C.N.M.

Table of content: (NPI 1235794124)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285608703 NPI number — MS. TARA SHANNON SMITH C.N.M.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SMITH
Provider First Name:
TARA
Provider Middle Name:
SHANNON
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
C.N.M.
Provider Gender Code:
F

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:
1285608703
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/15/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
26005 RIDGE RD
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
DAMASCUS
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
20872-1892
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
301-414-2300
Provider Business Mailing Address Fax Number:
301-414-2306

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
26005 RIDGE RD
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
DAMASCUS
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
20872-1892
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
301-414-2300
Provider Business Practice Location Address Fax Number:
301-414-2306
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: 176B00000X , with the licence number:  0024165986 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 163W00000X , with the licence number: 0001146963 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 367A00000X , with the licence number: AC00911 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 010130484 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7002042 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 175079 . This is a "ANTHEM" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 010061873 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2125746 . This is a "UHC/MAMSI" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 75928N . This is a "SENTARA/OPTIMA" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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