Provider Demographics
NPI: | 1134112428 |
---|---|
Name: | SMITH, BLAINE E (MD) |
Entity Type: | Individual |
Prefix: | DR |
First Name: | BLAINE |
Middle Name: | E |
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: | PO BOX 404442 |
Mailing Address - Street 2: | |
Mailing Address - City: | ATLANTA |
Mailing Address - State: | GA |
Mailing Address - Zip Code: | 30384-4442 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 804-756-5130 |
Mailing Address - Fax: | 804-672-6899 |
Practice Address - Street 1: | 8601 VETERANS HWY |
Practice Address - Street 2: | SUITE 100 |
Practice Address - City: | MILLERSVILLE |
Practice Address - State: | MD |
Practice Address - Zip Code: | 21108-1547 |
Practice Address - Country: | US |
Practice Address - Phone: | 410-729-4451 |
Practice Address - Fax: | 410-729-4470 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2005-08-23 |
Last Update Date: | 2008-02-11 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
MD | D0021406 | 2085R0202X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 2085R0202X | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
DC | 38110057 | Other | CAREFIRST BCBS |
MD | KC46SH42453901 | Other | CAREFIRST BCBS |
MD | H380C438 | Medicare PIN | |
MD | 545LF649 | Medicare PIN | |
MD | 865LC437 | Medicare PIN | |
MD | E15174 | Medicare UPIN |