Provider Demographics
NPI:1619082245
Name:SMITH, PHYLLIS J (CRNA)
Entity Type:Individual
Prefix:MRS
First Name:PHYLLIS
Middle Name:J
Last Name:SMITH
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 WEST RD
Mailing Address - Street 2:SUITE 210
Mailing Address - City:TOWSON
Mailing Address - State:MD
Mailing Address - Zip Code:21204-2316
Mailing Address - Country:US
Mailing Address - Phone:410-296-4616
Mailing Address - Fax:410-337-5068
Practice Address - Street 1:6701 N CHARLES ST
Practice Address - Street 2:
Practice Address - City:TOWSON
Practice Address - State:MD
Practice Address - Zip Code:21204-6808
Practice Address - Country:US
Practice Address - Phone:410-296-4616
Practice Address - Fax:410-337-5068
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2010-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCRN48155367500000X
NC119768367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD000828100Medicaid
NC8050134Medicaid
SCNAN771Medicaid
SCNAN771Medicaid
MD193162ZCXJMedicare PIN
NC8050134Medicaid
MD000828100Medicaid