Provider Demographics
NPI:1649226309
Name:SMITH, SAMUEL R (DC)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:R
Last Name:SMITH
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:279 WEST MAIN STREET
Mailing Address - Street 2:#8
Mailing Address - City:MIDDLETOWN
Mailing Address - State:PA
Mailing Address - Zip Code:17057-1222
Mailing Address - Country:US
Mailing Address - Phone:717-944-0004
Mailing Address - Fax:717-944-7710
Practice Address - Street 1:279 WEST MAIN STREET
Practice Address - Street 2:#8
Practice Address - City:MIDDLETOWN
Practice Address - State:PA
Practice Address - Zip Code:17057-1222
Practice Address - Country:US
Practice Address - Phone:717-944-0004
Practice Address - Fax:717-944-7710
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC1776L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA5704220604120OtherAETNA PPO - AETNA HMO
PA02441400OtherCAPITAL BLUE CROSS
PASM032628Medicare ID - Type Unspecified