Provider Demographics
NPI:1295113322
Name:SMITH, BENJAMIN
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3879 MAGGIES PL
Mailing Address - Street 2:
Mailing Address - City:IRONDALE
Mailing Address - State:AL
Mailing Address - Zip Code:35210-5509
Mailing Address - Country:US
Mailing Address - Phone:205-269-4024
Mailing Address - Fax:
Practice Address - Street 1:3879 MAGGIES PL
Practice Address - Street 2:
Practice Address - City:IRONDALE
Practice Address - State:AL
Practice Address - Zip Code:35210-5509
Practice Address - Country:US
Practice Address - Phone:205-269-4024
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-08
Last Update Date:2015-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-135255367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered