1760457980 NPI number — RANDALL S SMITH MD

Table of content: RANDALL S SMITH MD (NPI 1760457980)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760457980 NPI number — RANDALL S SMITH MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SMITH
Provider First Name:
RANDALL
Provider Middle Name:
S
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1760457980
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/25/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5700 SOUTHWYCK BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TOLEDO
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
43614-1509
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-288-8325
Provider Business Mailing Address Fax Number:
419-866-5453

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
969 LAKELAND DRIVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JACKSON
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39216-4699
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-200-3840
Provider Business Practice Location Address Fax Number:
601-200-8801
Provider Enumeration Date:
02/21/2006

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: 207ZP0102X , with the licence number:  13000 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 05774275 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 981416 . This is a "WESTERN OHIO HEALTHCARE" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: 4227432 . This is a "AETNA" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: P00305343 . This is a "MEDICARE RR" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".




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