Provider Demographics
NPI:1609802867
Name:OLIVIA SMITH-BLACKWELL MD PC
Entity Type:Organization
Organization Name:OLIVIA SMITH-BLACKWELL MD PC
Other - Org Name:MEADOW FAMILY MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:OLIVIA
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH-BLACKWELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:716-693-4600
Mailing Address - Street 1:908 NIAGARA FALLS BLVD
Mailing Address - Street 2:SUITE 208
Mailing Address - City:NORTH TONAWANDA
Mailing Address - State:NY
Mailing Address - Zip Code:14120-2019
Mailing Address - Country:US
Mailing Address - Phone:716-692-3302
Mailing Address - Fax:716-332-3525
Practice Address - Street 1:533 MEADOW DR
Practice Address - Street 2:#2
Practice Address - City:NORTH TONAWANDA
Practice Address - State:NY
Practice Address - Zip Code:14120-2835
Practice Address - Country:US
Practice Address - Phone:716-693-4600
Practice Address - Fax:716-693-4807
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-22
Last Update Date:2011-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02632800Medicaid
NYBA0413Medicare ID - Type Unspecified