1558416214 NPI number — GEORGE JAY WALKER SMITH SR. M.D.

Table of content: VIENNA MUENI MUNGUTI (NPI 1255045993)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558416214 NPI number — GEORGE JAY WALKER SMITH SR. M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SMITH
Provider First Name:
GEORGE
Provider Middle Name:
JAY WALKER
Provider Name Prefix Text:
Provider Name Suffix Text:
SR.
Provider Credential Text:
M.D.
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:
1558416214
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
160 ALLEN ST
Provider Second Line Business Mailing Address:
RUTLAND REGIONAL MEDICAL CENTER - PATHOLOGY LAB
Provider Business Mailing Address City Name:
RUTLAND
Provider Business Mailing Address State Name:
VT
Provider Business Mailing Address Postal Code:
05701-4560
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
802-747-1789
Provider Business Mailing Address Fax Number:
802-747-6525

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
160 ALLEN ST
Provider Second Line Business Practice Location Address:
RUTLAND REGIONAL MEDICAL CENTER - PATHOLOGY LAB
Provider Business Practice Location Address City Name:
RUTLAND
Provider Business Practice Location Address State Name:
VT
Provider Business Practice Location Address Postal Code:
05701-4560
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
802-747-1789
Provider Business Practice Location Address Fax Number:
802-747-6525
Provider Enumeration Date:
01/24/2007

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: 207ZP0102X , with the licence number:  042-0009681 , registered in the state of VT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0048280 . This is a "BLUE SHIELD VT" identifier , issued by the state of ( VT ) . This identifiers is of the category "OTHER".
  • Identifier: OVN2023 , issued by the state of ( VT ) . This identifiers is of the category "MEDICAID".