Provider Demographics
NPI:1508937723
Name:SMITH, ROBERT W (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:W
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 1:68278 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BLOUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35031-3370
Mailing Address - Country:US
Mailing Address - Phone:205-429-4151
Mailing Address - Fax:205-429-3378
Practice Address - Street 1:68278 MAIN ST
Practice Address - Street 2:
Practice Address - City:BLOUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35031-3370
Practice Address - Country:US
Practice Address - Phone:205-429-4151
Practice Address - Fax:205-429-4604
Is Sole Proprietor?:No
Enumeration Date:2006-11-10
Last Update Date:2012-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL10508207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009959550Medicaid
AL009975215Medicaid
AL051502640Medicare ID - Type UnspecifiedBLOUNSTVILLE LOCATION
AL051555338Medicare ID - Type UnspecifiedONEONTA LOCATION
AL009975215Medicaid