Provider Demographics
NPI:1003815440
Name:SMITH, PHILIP SHERIDAN (MD)
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:SHERIDAN
Last Name:SMITH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:164 WILLOW AVE
Mailing Address - Street 2:
Mailing Address - City:CORNWALL
Mailing Address - State:NY
Mailing Address - Zip Code:12518-1329
Mailing Address - Country:US
Mailing Address - Phone:845-534-8271
Mailing Address - Fax:845-534-8145
Practice Address - Street 1:164 WILLOW AVE
Practice Address - Street 2:
Practice Address - City:CORNWALL
Practice Address - State:NY
Practice Address - Zip Code:12518-1329
Practice Address - Country:US
Practice Address - Phone:845-534-8271
Practice Address - Fax:845-534-8145
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-19
Last Update Date:2014-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY144650207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY75D541OtherEMPIRE BC/BS
NY00966629Medicaid
NY00966629Medicaid
B79285Medicare UPIN