Provider Demographics
NPI:1023186061
Name:SMITH, BRIAN KEITH (MD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:KEITH
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 1:8324 OSWEGO RD
Mailing Address - Street 2:STE D
Mailing Address - City:LIVERPOOL
Mailing Address - State:NY
Mailing Address - Zip Code:13090-1086
Mailing Address - Country:US
Mailing Address - Phone:315-652-6551
Mailing Address - Fax:315-652-7039
Practice Address - Street 1:8324 OSWEGO RD
Practice Address - Street 2:STE D
Practice Address - City:LIVERPOOL
Practice Address - State:NY
Practice Address - Zip Code:13090-1086
Practice Address - Country:US
Practice Address - Phone:315-652-6551
Practice Address - Fax:315-652-7039
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2018-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY173977207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01833178Medicaid
990459OtherMVP HEALTHCARE
080178299OtherRAILROAD MEDICARE
E15668Medicare UPIN
CC7707Medicare ID - Type Unspecified