1649210832 NPI number — STACEY A SMITH MD

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649210832 NPI number — STACEY A SMITH MD

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:

SMITH

Provider First Name:

STACEY

Provider Middle Name:

A

Provider Name Prefix Text:

Provider Name Suffix Text:

Provider Credential Text:

MD

Provider Gender Code:

M

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:

1649210832

Entity Type Code:

Individual

Replacement NPI:

Last Update Date:

11/28/2011

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

211 E MILL ST

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:

PELICAN RAPIDS

Provider Business Mailing Address State Name:

MN

Provider Business Mailing Address Postal Code:

56572-4234

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

218-863-6100

Provider Business Mailing Address Fax Number:

Provider First Line Business Practice Location Address:

211 E MILL ST

Provider Second Line Business Practice Location Address:

Provider Business Practice Location Address City Name:

PELICAN RAPIDS

Provider Business Practice Location Address State Name:

MN

Provider Business Practice Location Address Postal Code:

56572-4234

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

218-863-6100

Provider Business Practice Location Address Fax Number:

Provider Enumeration Date:

06/07/2006

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

• Taxonomy code: 207Q00000X , with the licence number:  44095 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: 0107063 . This is a "MEDICA #" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
• Identifier: 20696 . This is a "NDBS #" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
• Identifier: 677682500 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
• Identifier: 1280970 . This is a "AMERICA'S PPO/ARAZ #" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
• Identifier: 43G89SM . This is a "MNBS #" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
• Identifier: 0107064 . This is a "MEDICA #" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
• Identifier: 142065 . This is a "UCARE #" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
• Identifier: DA9031028234 . This is a "PREFERRED ONE #" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
• Identifier: 11146 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
• Identifier: HP38211 . This is a "HEALTHPARTNERS #" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
• Identifier: MN100045 . This is a "LHS/BANNERHEALTH #" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".