Provider Demographics
NPI:1427029479
Name:SMITH, GEORGE EDMOND (MD)
Entity Type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:EDMOND
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 1:1444 W. PASSYUNK AVE.
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19145
Mailing Address - Country:US
Mailing Address - Phone:337-244-4220
Mailing Address - Fax:
Practice Address - Street 1:1444 W PASSYUNK AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19145-2312
Practice Address - Country:US
Practice Address - Phone:337-244-4220
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-29
Last Update Date:2017-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD034972E207Q00000X
LA1448-4R207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAC30934Medicare UPIN
LA1476267Medicaid
LA4J9406Medicare ID - Type Unspecified