Provider Demographics
NPI:1922047562
Name:SMITH, THOMAS G (MD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:G
Last Name:SMITH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:33398 WALKER RD
Mailing Address - Street 2:SUITE C
Mailing Address - City:AVON LAKE
Mailing Address - State:OH
Mailing Address - Zip Code:44012-1496
Mailing Address - Country:US
Mailing Address - Phone:440-930-8630
Mailing Address - Fax:440-930-8676
Practice Address - Street 1:33398 WALKER RD
Practice Address - Street 2:SUITE C
Practice Address - City:AVON LAKE
Practice Address - State:OH
Practice Address - Zip Code:44012-1496
Practice Address - Country:US
Practice Address - Phone:440-930-8630
Practice Address - Fax:440-930-8676
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-06
Last Update Date:2008-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH350363792080A0000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0322001Medicaid
SM0818522Medicare ID - Type Unspecified
OHG44721Medicare UPIN