Provider Demographics
NPI:1134112428
Name:SMITH, BLAINE E (MD)
Entity type:Individual
Prefix:DR
First Name:BLAINE
Middle Name:E
Last Name:SMITH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 404442
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-4442
Mailing Address - Country:US
Mailing Address - Phone:804-756-5130
Mailing Address - Fax:804-672-6899
Practice Address - Street 1:8601 VETERANS HWY
Practice Address - Street 2:SUITE 100
Practice Address - City:MILLERSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21108-1547
Practice Address - Country:US
Practice Address - Phone:410-729-4451
Practice Address - Fax:410-729-4470
Is Sole Proprietor?:No
Enumeration Date:2005-08-23
Last Update Date:2008-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD00214062085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC38110057OtherCAREFIRST BCBS
MDKC46SH42453901OtherCAREFIRST BCBS
MDH380C438Medicare PIN
MD545LF649Medicare PIN
MD865LC437Medicare PIN
MDE15174Medicare UPIN