Provider Demographics
NPI:1881821619
Name:SMITH, TIM ALLEN (MD)
Entity Type:Individual
Prefix:
First Name:TIM
Middle Name:ALLEN
Last Name:SMITH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2501 KEENAN DR
Mailing Address - Street 2:
Mailing Address - City:INTERNATIONAL FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:56649-2181
Mailing Address - Country:US
Mailing Address - Phone:218-283-9431
Mailing Address - Fax:
Practice Address - Street 1:2501 KEENAN DR
Practice Address - Street 2:
Practice Address - City:INTERNATIONAL FALLS
Practice Address - State:MN
Practice Address - Zip Code:56649-2181
Practice Address - Country:US
Practice Address - Phone:218-283-9431
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-19
Last Update Date:2016-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN53656208D00000X, 2084P0800X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1881821619Medicaid
WI1881821619Medicaid