Provider Demographics
NPI:1235502493
Name:THE SMITH LLC
Entity Type:Organization
Organization Name:THE SMITH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:262-844-1818
Mailing Address - Street 1:9545 S 20TH ST STE 2
Mailing Address - Street 2:
Mailing Address - City:OAK CREEK
Mailing Address - State:WI
Mailing Address - Zip Code:53154-4929
Mailing Address - Country:US
Mailing Address - Phone:262-844-1818
Mailing Address - Fax:
Practice Address - Street 1:9545 S 20TH ST STE 2
Practice Address - Street 2:
Practice Address - City:OAK CREEK
Practice Address - State:WI
Practice Address - Zip Code:53154-4929
Practice Address - Country:US
Practice Address - Phone:262-844-1818
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-09
Last Update Date:2015-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2664-12305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI188165045Medicaid
WI012340013Medicare Oscar/Certification
WI188165045Medicaid