Provider Demographics
NPI:1891993713
Name:SMITH CLINIC P A
Entity Type:Organization
Organization Name:SMITH CLINIC P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:OLIVER
Authorized Official - Middle Name:D
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-521-5936
Mailing Address - Street 1:3669 ELLENDALE CIRCLE
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83406
Mailing Address - Country:US
Mailing Address - Phone:208-521-5936
Mailing Address - Fax:208-524-5608
Practice Address - Street 1:3669 ELLENDALE CIR
Practice Address - Street 2:
Practice Address - City:AMMON
Practice Address - State:ID
Practice Address - Zip Code:83406-4749
Practice Address - Country:US
Practice Address - Phone:208-521-5936
Practice Address - Fax:208-524-5608
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-03
Last Update Date:2008-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1376755Medicare ID - Type Unspecified