Provider Demographics
NPI:1710173109
Name:MARY M SMYTH MD PC
Entity Type:Organization
Organization Name:MARY M SMYTH MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:M
Authorized Official - Last Name:SMYTH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:508-674-3500
Mailing Address - Street 1:PO BOX 9503
Mailing Address - Street 2:
Mailing Address - City:FALL RIVER
Mailing Address - State:MA
Mailing Address - Zip Code:02720
Mailing Address - Country:US
Mailing Address - Phone:508-674-3500
Mailing Address - Fax:508-674-3535
Practice Address - Street 1:1030 PRESIDENT AVE
Practice Address - Street 2:SUITE 302
Practice Address - City:FALL RIVER
Practice Address - State:MA
Practice Address - Zip Code:02720
Practice Address - Country:US
Practice Address - Phone:508-674-3500
Practice Address - Fax:508-674-3535
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-19
Last Update Date:2008-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA082086207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3148335Medicaid
MAF57286Medicare UPIN
MAA20977Medicare PIN