Provider Demographics
NPI:1083680128
Name:SMITH, MARY-ELISE (MD)
Entity Type:Individual
Prefix:
First Name:MARY-ELISE
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MARY-ELISE
Other - Middle Name:
Other - Last Name:MANUELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 40
Mailing Address - Street 2:
Mailing Address - City:SOUTHBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:01550-0040
Mailing Address - Country:US
Mailing Address - Phone:508-909-7799
Mailing Address - Fax:508-764-2432
Practice Address - Street 1:10 NORTH MAIN STREET
Practice Address - Street 2:
Practice Address - City:CHARLTON
Practice Address - State:MA
Practice Address - Zip Code:01507
Practice Address - Country:US
Practice Address - Phone:508-248-1770
Practice Address - Fax:208-248-1769
Is Sole Proprietor?:No
Enumeration Date:2006-02-28
Last Update Date:2015-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA82206207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAG64984Medicare UPIN
MAUX8079Medicare PIN
MA3177068Medicaid