Provider Demographics
NPI:1033102330
Name:SMART FORM INC
Entity Type:Organization
Organization Name:SMART FORM INC
Other - Org Name:SMART FOAM CORSET SHOP
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:GENERAL MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LAURIE
Authorized Official - Middle Name:J
Authorized Official - Last Name:CHURMA
Authorized Official - Suffix:
Authorized Official - Credentials:BOC CERTIFIED
Authorized Official - Phone:412-281-9913
Mailing Address - Street 1:100 5TH AVE
Mailing Address - Street 2:SUITE 804
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15222-1821
Mailing Address - Country:US
Mailing Address - Phone:412-281-9913
Mailing Address - Fax:412-281-8074
Practice Address - Street 1:100 5TH AVE
Practice Address - Street 2:SUITE 804
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15222-1821
Practice Address - Country:US
Practice Address - Phone:412-281-9913
Practice Address - Fax:412-281-8074
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0016096020001Medicaid
PA0016096020001Medicaid