Provider Demographics
NPI:1790967974
Name:JAY L. SMITH MD
Entity Type:Organization
Organization Name:JAY L. SMITH MD
Other - Org Name:BOWLING GREEN PAIN CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAY
Authorized Official - Middle Name:L
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:419-354-6166
Mailing Address - Street 1:1072 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:OH
Mailing Address - Zip Code:43402-1346
Mailing Address - Country:US
Mailing Address - Phone:419-354-6166
Mailing Address - Fax:419-354-6756
Practice Address - Street 1:1072 N MAIN ST
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:OH
Practice Address - Zip Code:43402-1346
Practice Address - Country:US
Practice Address - Phone:419-354-6166
Practice Address - Fax:419-354-6756
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-29
Last Update Date:2012-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2197111N00000X
OH35-04-4006207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
=========007OtherMEDICAL MUTUAL OF OHIO
=========3A00OtherANTHEM BCBS
=========008OtherMEDICAL MUTUAL OF OHIO
=========009OtherMEDICAL MUTUAL OF OHIO
OH=========-00OtherWORKERS COMP
=========009OtherMEDICAL MUTUAL OF OHIO