Provider Demographics
NPI:1437110939
Name:SMITH, JACK E (MD)
Entity Type:Individual
Prefix:DR
First Name:JACK
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 1:5750 CENTRE AVE
Mailing Address - Street 2:SUITE 510
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15206-3709
Mailing Address - Country:US
Mailing Address - Phone:412-924-1100
Mailing Address - Fax:412-924-1111
Practice Address - Street 1:5750 CENTRE AVE
Practice Address - Street 2:SUITE 510
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15206-3721
Practice Address - Country:US
Practice Address - Phone:412-924-1100
Practice Address - Fax:412-924-1111
Is Sole Proprietor?:No
Enumeration Date:2006-04-01
Last Update Date:2014-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD034721E174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA00060300OtherHIGHMARK
PAP00290974OtherRAILROAD MEDICARE
PA001042460006Medicaid
PAC87680Medicare UPIN
PA001042460006Medicaid