1467547257 NPI number — DR. MAURICE BRADLEY SMITH PH.D.,L.P.

Table of content: (NPI 1962572297)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467547257 NPI number — DR. MAURICE BRADLEY SMITH PH.D.,L.P.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SMITH
Provider First Name:
MAURICE
Provider Middle Name:
BRADLEY
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PH.D.,L.P.
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:
1467547257
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/06/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1935 COUNTY ROAD B2 W STE 270
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROSEVILLE
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55113-2785
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-481-0664
Provider Business Mailing Address Fax Number:
651-846-5877

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1935 COUNTY ROAD B2 W STE 270
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROSEVILLE
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55113-2785
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-481-0664
Provider Business Practice Location Address Fax Number:
651-846-5877
Provider Enumeration Date:
10/04/2006

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: 103TC0700X , with the licence number:  LP0783 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 103TM1800X , with the licence number: LP0783 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: HP21325 . This is a "HEALTH PARTNERS INSURANCE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 27F90SM . This is a "BLUE CROSS/BLUE SHIELD" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 6150656 . This is a "MEDICA/UNITED BEH. HEALTH" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 680016304 . This is a "RAIL ROAD MEDICARE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 092353200 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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