1720052996 NPI number — MR. MICHAEL DEAN SMITH NBC HIS

Table of content: MR. MICHAEL DEAN SMITH NBC HIS (NPI 1720052996)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720052996 NPI number — MR. MICHAEL DEAN SMITH NBC HIS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SMITH
Provider First Name:
MICHAEL
Provider Middle Name:
DEAN
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
NBC HIS
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:
1720052996
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/16/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6700 WASHINGTON AVE S
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EDEN PRAIRIE
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55344-3405
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
612-351-1529
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 S WILSON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JEFFERSON
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
50129
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
515-386-2443
Provider Business Practice Location Address Fax Number:
515-233-1012
Provider Enumeration Date:
02/15/2006

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: 237600000X , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 237700000X , with the licence number: 496 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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