1790779775 NPI number — MARK RANDALL SMITH PHD

Table of content: MARK RANDALL SMITH PHD (NPI 1790779775)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790779775 NPI number — MARK RANDALL SMITH PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SMITH
Provider First Name:
MARK
Provider Middle Name:
RANDALL
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PHD
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:
1790779775
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/30/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
904 HWY 15 SOUTH FRONTAGE RD.
Provider Second Line Business Mailing Address:
SUITE H
Provider Business Mailing Address City Name:
HUTCHINSON
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55350
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
320-587-2939
Provider Business Mailing Address Fax Number:
320-864-1927

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
904 HWY 15 SOUTH FRONTAGE RD.
Provider Second Line Business Practice Location Address:
SUITE H
Provider Business Practice Location Address City Name:
HUTCHINSON
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55350
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
320-587-2939
Provider Business Practice Location Address Fax Number:
320-864-1927
Provider Enumeration Date:
09/07/2005

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: 103T00000X , with the licence number:  LP2907 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 24981 . This is a "HEALTH PARTNERS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 6120057 . This is a "UNITED BEH HEALTH" identifier . This identifiers is of the category "OTHER".
  • Identifier: 262248300 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0004049 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 112964 . This is a "CHOICE PLUS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 030701079 . This is a "PRIME WEST HEALTH SYST" identifier . This identifiers is of the category "OTHER".
  • Identifier: 990991000146 . This is a "PREFERRED ONE/BHP" identifier . This identifiers is of the category "OTHER".
  • Identifier: 53308SM . This is a "BC" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 98520 . This is a "BC" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 115129 . This is a "UCARE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com