Provider Demographics
NPI:1902842610
Name:SMITH, THOMAS BALLENGER (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:BALLENGER
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 1:516 W 14TH AVE
Mailing Address - Street 2:STE 100
Mailing Address - City:HOLDREGE
Mailing Address - State:NE
Mailing Address - Zip Code:68949-1216
Mailing Address - Country:US
Mailing Address - Phone:308-995-4431
Mailing Address - Fax:308-995-3247
Practice Address - Street 1:516 W 14TH AVE
Practice Address - Street 2:STE 100
Practice Address - City:HOLDREGE
Practice Address - State:NE
Practice Address - Zip Code:68949-1216
Practice Address - Country:US
Practice Address - Phone:308-995-4431
Practice Address - Fax:308-995-3247
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2014-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE15286207R00000X, 173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes173000000XOther Service ProvidersLegal Medicine
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
089196Medicare PIN
NE0423750001Medicare NSC
B67782Medicare UPIN