Provider Demographics
NPI:1629280599
Name:SMITH, MARK GREGORY (RRT)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:GREGORY
Last Name:SMITH
Suffix:
Gender:M
Credentials:RRT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4549 CANDLEWOOD PL
Mailing Address - Street 2:APT. 305
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57702-1605
Mailing Address - Country:US
Mailing Address - Phone:240-422-1979
Mailing Address - Fax:
Practice Address - Street 1:4549 CANDLEWOOD PL
Practice Address - Street 2:APT. 305
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57702-1605
Practice Address - Country:US
Practice Address - Phone:240-422-1979
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCRC250227900000X
PAYM006446L227900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered227900000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, Registered