1487627238 NPI number — MR. HENRY KYLE SMITH DO

Table of content: MR. HENRY KYLE SMITH DO (NPI 1487627238)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487627238 NPI number — MR. HENRY KYLE SMITH DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SMITH
Provider First Name:
HENRY
Provider Middle Name:
KYLE
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
DO
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:
1487627238
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/09/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
945 E PARK DR
Provider Second Line Business Mailing Address:
STE 102
Provider Business Mailing Address City Name:
HARRISBURG
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
17111-2804
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
717-561-4940
Provider Business Mailing Address Fax Number:
717-561-4999

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10413 S YALE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TULSA
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74137-6065
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
717-561-4940
Provider Business Practice Location Address Fax Number:
717-561-4999
Provider Enumeration Date:
02/10/2006

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: 2085R0202X , with the licence number:  05002617L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0628327 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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