1588635536 NPI number — DELIA A SMITH PT

Table of content: DELIA A SMITH PT (NPI 1588635536)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588635536 NPI number — DELIA A SMITH PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SMITH
Provider First Name:
DELIA
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT
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:
1588635536
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/20/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 3333
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ASHLAND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97520-0312
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-621-9373
Provider Business Mailing Address Fax Number:
866-746-1959

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
24 MYRTLE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MEDFORD
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97504-7338
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-621-9373
Provider Business Practice Location Address Fax Number:
866-746-1959
Provider Enumeration Date:
01/29/2006

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: 225100000X , with the licence number:  3776 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 840221000 . This is a "REGENCE BLUE CROSS" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 227906 . This is a "OMAP" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 11260502 . This is a "CAQH IDENTIFICATIO NUMBER" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".




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