Provider Demographics
NPI:1871505735
Name:SCOTT D SMOLLER MD PA
Entity Type:Organization
Organization Name:SCOTT D SMOLLER MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:
Authorized Official - Last Name:SMOLLER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:954-452-5188
Mailing Address - Street 1:180 SW 84TH AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:PLANTATION
Mailing Address - State:FL
Mailing Address - Zip Code:33324-2731
Mailing Address - Country:US
Mailing Address - Phone:954-452-5188
Mailing Address - Fax:954-474-0277
Practice Address - Street 1:180 SW 84TH AVE
Practice Address - Street 2:SUITE C
Practice Address - City:PLANTATION
Practice Address - State:FL
Practice Address - Zip Code:33324-2731
Practice Address - Country:US
Practice Address - Phone:954-452-5188
Practice Address - Fax:954-474-0277
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-12
Last Update Date:2009-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0036893207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL94270Medicare PIN
94270YMedicare PIN
D79565Medicare UPIN
FLAD715Medicare UPIN
AD715Medicare PIN
94270Medicare PIN
FL94270YMedicare PIN
FLD79565Medicare UPIN