Provider Demographics
NPI:1619184652
Name:GREGG SMITH D.O., P.C.
Entity Type:Organization
Organization Name:GREGG SMITH D.O., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GREGG
Authorized Official - Middle Name:A
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:480-242-6297
Mailing Address - Street 1:1042 N HIGLEY RD
Mailing Address - Street 2:SUITE 102-602
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85205-5398
Mailing Address - Country:US
Mailing Address - Phone:480-242-6297
Mailing Address - Fax:480-699-3129
Practice Address - Street 1:1042 N HIGLEY RD
Practice Address - Street 2:SUITE 102-602
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85205-5398
Practice Address - Country:US
Practice Address - Phone:480-242-6297
Practice Address - Fax:480-699-3129
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-17
Last Update Date:2010-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2813208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ318198Medicaid
AZ318198Medicaid
F66758Medicare UPIN