Provider Demographics
NPI:1992856256
Name:SMYLES, JOHN M (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:M
Last Name:SMYLES
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 1:1 W ELM ST
Mailing Address - Street 2:
Mailing Address - City:CONSHOHOCKEN
Mailing Address - State:PA
Mailing Address - Zip Code:19428-4108
Mailing Address - Country:US
Mailing Address - Phone:215-830-9991
Mailing Address - Fax:215-830-0375
Practice Address - Street 1:2601 HOLME AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19152-2007
Practice Address - Country:US
Practice Address - Phone:215-335-6144
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-15
Last Update Date:2017-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD029250E2085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0448826OtherBLUE SHIELD
PA058221000OtherINDEPENDECE BLUE CROSS
PA0014681570003Medicaid
PA0014681570003Medicaid
E60388Medicare UPIN